“Today a million people wait on hospital waiting lists. The NHS is strangled by red tape, threatened with creeping privatisation, with more people feeling they have no alternative but to go private.”
So said Tony Blair, leader of the opposition, in April of 1997. The charge of creeping privatisation was leveled at the Conservatives after an 18-fold increase in spending by GP fundholders on the private sector. In 1991-92 GP fundholders spent under £4 million on buying private services for their patients, by 1995-96 it was up to £66 million. Total hospital and community health spending at the time was £25 billion, but Labour MPs were concerned that the movement of funds was depriving NHS hospitals of funding. Hugh Bayley MP, a Labour health economist, said at the time.
“Almost all of the GP spending in the private sector is on outpatient consultations and elective procedures which the NHS provides. You could not have clearer evidence of the Conservatives’ creeping privatisation of the NHS. They are plunging NHS hospitals into financial crisis by switching money from the NHS to private practice.”
Times have moved on. Now the accusation of creeping privatisation is leveled at Labour. The use of the private sector in the NHS by Labour was started in 2000 with the widely disliked PFI schemes to build new hospitals. More recently, concern has been expressed about the involvement of private companies in providing general practitioner services. This concern goes back to 2005, when general practitioner services in Sedgefield, ironically Tony Blair’s constituency, were taken over by a private company. The deputy chairman of the BMA’s GP committee said at the time, “GPs don’t like this. This is privatisation by stealth, but it is inevitable, if GPs can’t provide the service then private companies will.”
However, what the BMA didn’t point out was that general practice in the UK was never nationalised. It can’t be privatised in the way the steel industry or the railways was. A salaried GP writes to the BMJ in the light of a editorial about private company involvement in the provision of primary care healthcare. He makes the point well.
Chris Salisbury repeats the commonly quoted argument that “private provision can create conflicts for doctors between what is best for patients and best for profits, and this can undermine trust between patients and doctors.”
While this is indeed a significant danger, the editorial implies that this conflict is unique to doctors working for private providers. It is an incredible achievement that, 60 years since general practices first contracted to provide services for the National Health Service, the profession has convinced the public, and sometimes even itself, that there is no profit motive involved in the way traditional partnerships run their surgeries. There is.
As a rule, every pound spent on nursing staff, medical equipment or premises is one less pound of profit for a partnership. One could even argue that a salaried general practitioner working for a private provider has less conflict of interest than a GP partner: the salaried GP is unlikely to receive much, if any, of the savings they make from their day to day decisions, while a partnership will receive 100% of any cost savings in practice expenditure.
While I share the other concerns raised by Professor Salisbury in his editorial about the role of private companies in primary care, it is important that we acknowledge the weaknesses as well as the strengths of the independent contractor system. It is our honesty and openness as a profession which has built up the trust that is now at stake. Ignoring inconvenient truths will not help our cause in the long run.
There are, predictably, left wing concerns about the privatisation of the NHS, and the creeping privatisation accusation has proliferated. General practitioners seem to have managed the neat trick of being viewed as part of the NHS by many, while at the same time remaining outside of it.
The British Medical Association (BMA), and in particular its general practitioner members, vigorously opposed the formation of the NHS. A BMJ leader written immediately before a BMA plebiscite about the NHS in 1948 argued that, “The conflict between Mr Bevan and the profession centres round one fundamental principle, and no assurance or gloss of interpretation from him can alter this fact. The National Heath Service Act commends itself to the political party in power because it leads unmistakably to the eventual establishment of a whole-time State medical service…”. A plebiscite about the NHS Act was a chance for the profession to consider “their continued existence as a body of free men.”
As the BMA’s opposition threatened the formation of the NHS, Bevan conceded that general practitioners could exist as self-employed contractors. They run small businesses subcontracted to the NHS. Since the formation of the NHS in 1948 general practitioners have immensely improved their financial status; pre-NHS general practice was not particularly financially rewarding. Indeed one of the arguments for the formation of a government salaried-service of GPs was that it might alleviate the financial distress of young doctors. General practitioners managed to maintain much of the professional independence they valued, while appreciating the security the NHS gave them. Only recently has that independence come under sustained pressure.
In a world of NICE guidance, National Service Frameworks, Primary Care Trusts, and clinical governance the space for professional independence has been squeezed, as it has been in other professions. Even the badly-negotiated target-driven contract that has led to large rises in general practitioner income can be viewed as an assault on professional independence, with its emphasis on targets to meet centrally agreed clinical objectives. The concern about the involvement of private firms in general practice should be viewed in this light. It is not a debate about the privatisation of the NHS, but a debate about a profession concerned about its professional independence. General practitioners are concerned about becoming a salaried service and losing control of their working environment.
There are questions to be asked about this process. Will salaried general practitioner services perform as well as independent small contractor general practitioners? Are there potential benefits of professional independence for patients? What will be lost if general practice is de-professionalised? Can we see the effects of de-professionalisation in other areas? Teaching is an obvious example to look at. Is there a widespread threat to general practice as we know it, or is there a place for some private company provision in areas where general practitioner services are lacking? Do polyclinics have some attractions?
This post is not designed to be an attack on general practitioners. However, to frame this debate as one about creeping privatisation is wrong. The fundamental principle on which the NHS was formed was that it should be a free health service available to all funded from taxation, to free patients from the fear of medical bills. The NHS is not about publically-owned buildings or state employed staff, but about outcomes for patients. Those on the left who oppose so-called “creeping privatisation” on principle should really be marching in favour of a nationalised salaried GP service. They should note that idea is likely to be considerably less popular. The use of private medicine to deliver NHS services has a long history. Why should private companies running general practices be any more objectionable than private individual businessmen running general practices? Shouldn’t the same pragmatism Bevan showed towards general practice be used today?
2 Comments
I don’t have any serious disagreement with this. I think it is an excellent overview of current problems. Of course I do not personally want to be salaried and on paye. I would lose financially. But that is my personal interest. GPs are still a very powerful group within the NHS, too powerful, and the government still has not learnt how to treat us and thus lurches from carrot to stick. I am an older, old fashioned GP still trying to practice personal relationship based family medicine. I believe that if we lose that, we lose a lot – but we have to accept that demands are different these days. GPs are going to go the way of old fashioned bank managers who genuinely looked after you, to be replaced by a plethora of HCPs and god knows what. 24/7 instant access to not very much.
I think, like you, those on both sides of the arguments need to ditch their personal Clause IVs, clean the black board, and look solely at how best to deliver a reasonable standard of health care to all UK citizens independent of wealth or status. If the best way is privatisation, then let’s do it. If it is total nationalisation, then let’s do it.
We were fundholders and bought lots of services for our patients from the private sector. But the private sector cherry picked. They did not do dementia, for example. That was left to the NHS which was now starved of funds.
No easy answers
John
One of the strengths of the NHS has always been solidarity across generations, health status and, to a surprisingly successful extent, class.
Hence the healthy, busy 30 year old with a single minor illness might well get a more accessible and perfectly adequate service outside traditional general practice but providing such a service to him risks destabilizing the traditional GP service for the elderly, those with complex multiple conditions and often conflicting treatments who really need a long term relationship with a holistic generalist who can interpret the protocols, the expert but narrow advice from increasingly specialised hospital based professionals and actually help such a patient make decisions about his or her treatment.
My typical surgery now often resembles what would have been a General Medical Hospital Outpatient Clinic 20 years ago, juggling the diabetic’s need for good sugar control with his need to lower his blood pressure, prevent his heart failing while controlling his cholesterol and avoiding side effects of medication.
That holistic, chronic care will be much harder to provide with privately employed doctors or protocol following nurses working on short term contracts (to minimize labour costs of large for profit multinationals).
Perhaps we will provide both services as the private providers cherry pick the easy, profitable, young patients and a dwindling NHS GP rump looks after the elderly, the demented, the housebound. But can we afford both, is it fair to our elderly and sick and what happens the fit 30year old when he gets old and sick and retires away from his handy for work Polyclinic?