One of the most striking aspects of the biggest reorganisation in the history of the NHS in recent years, estimated to cost about £3bn, is that it manifests glaring gaps in legislation. There is not a single clause on patient safety, save for abolishing the National Patient Safety Agency. It also does not discuss general practitioners themselves. It does contain a nice legislative framework however for the law anticipated for scenarios (sic) quite close to asset stripping, in the event that NHS Trusts have to be wound up due to insufficient funds.

I took a relative to have her ear syringed this morning in a local general practice, and I was thinking only this morning how general practice would be likely to have a backdoor reconfiguration in the next parliament whoever is in power.

I personally am fed up of even hearing about, let alone discussing, the “Tony Blair Dictum”. I prefer to think of it now as “The Deceptive London Cab Analogy“. The Dictum in its various manifestations states that it doesn’t matter who provides my NHS services, as long as it’s of good quality and free at the point of use et cetera. I have always found the idea of private providers freeloading on the goodwill and reputation of the NHS as odd, when presumably they wish to establish the quality and kudos of their own distinctive services. I think the “Deceptive London Cab Analogy”, in that I don’t particularly care if it is actually a London cab, as long as it looks like a London Cab, and gets me from A to B (for example the Royal College of Surgeons in Lincoln’s Inn Fields to the Royal College of Physicians in St Andrew’s Place). It’s a bonus actually if it costs me less. I don’t care how it gets me there; in effect, there’s no difference between using a SatNav or somebody who has done 4 years of “The Knowledge” and has been examined accordingly.

Primary care is of course “the elephant” in the room, in that everyone knows that certain multi-nationals, assisted by liberalisation of international free trade, are licking their lips. It’s yet another one of those unmentioned topics in policy, like the NHS McKinsey efficiency or productivity savings, co-payments or personal health budgets. The whole world knows the existence of policy forks in the world, except none of the established traditional parties wish to discuss precisely the details. And people within thinktanks can continue to spin their motherhood and apple pie, in the hope that they can curry favour with an incoming administration. But it’s important for us who have other views on this to make such views known clear, otherwise a political party, including Labour, could legislate through the backdoor based on conversations also done behind-the-scenes. The public, whilst fed up about this ‘democratic deficit‘, are relatively powerless over it.

In 2010, Apax Partners published a revealing document entitled, “Opportunities: Post Global Healthcare Reforms“. The Apax Partners Global Healthcare Conference, which took place in New York in October 2010, sought opinions about the future of healthcare from some interested stakeholders. The ideology of the document is clear:

“With over 1.3 million employees, the UK’s National Health Service (NHS) is the world’s fourth largest employer and one of the most monolithic state providers of healthcare services.”

It is the ultimate nirvana for a businessman to find a new market. And general practice is articulated in those terms in the Apax document:

“The other change that (Mark) Britnell sees in the UK is even more fundamental: “In future, The NHS will be a state insurance provider not a state deliverer.”

Mark Britnell has been previously mooted as a possible contender for the replacement of Sir David Nicholson in the Health Services Journal.

The main problem about the current NHS top-down reorganisation is that it is important to identify the correct problem before producing an appropriate solution. If the problem which the Government wished to address was how to outsource and increase the number of private providers in the NHS, the solution, if implemented successfully, can be considered to be appropriate. When McKinsey sneezes, English health policy catches a cold. In this regard, McKinsey’s document, entitled “Five strategies for improving primary care” (“Report”; to download, please follow this link) provides some useful pointers. Affirming the importance of this market, the authors (Elisabeth Hansson and Sorcha McKenna) begin with the statement, “Primary care is pivotal to any health system.” Indeed, the first identified problem is that ‘in many countries, patients are dissatisfied with their ability to see GPs in a timely fashion.’ This is of course a problem which the operations management of any State-run service can address too. It is reported that, in Sweden, for example, many patients report that they cannot get timely access to their GP, especially by telephone. This is conceivably something which patient groups or the Royal College of General Practitioners could collect data on (and there is no shortage of data collection in primary care in the name of QOF) to improve the quality of the service.

It is mooted that, “the productivity of British GPs, for example, has dropped sharply in the past 15 years despite the fact that the government has markedly increased what it pays them“, on page 71, but this will be strongly contested by British GPs one assumes. The Report specifically discusses QOF thus:

“The United Kingdom has attempted to improve the quality of its primary care services through a new program, the Quality and Outcomes Framework (QOF), which gives GPs additional payments if they meet specified outcome metrics (for instance, the percentage of hypertensive patients whose blood pressure is lowered to the normal range). The program has been successful in focusing attention and improving scores on those metrics, but it has become clear that a GP’s performance on those metrics does not always reflect the overall quality of his or her practice.”

There has been, particularly since Kenneth Clarke’s “The Health of the Nation” paper in the 1980s, an enthusiasm for GPs to be paid to collect data, but such data has to be meaningful.

Consistent with the Health and Social Care Act (2012), and the pivotal section 75 which acted as the rocket boosters for introducing competitive tendering formally into the English NHS, the document argues that:

“In both tax-based and insurance-based systems, competition is a way to increase GP  productivity and the quality of care, because it signals to physicians that they will have to perform better if they want to retain their contracts and patients.”

This has only this week been powerfully rebutted by Professor Amanda Howe (MA Med MD FRCGP), Honorary Secretary of Council the Royal College of General Practitioners, in her response to Monitor as a member of Council (as linked here):

“The RCGP welcomes Monitor’s stated aim to better understand the challenges faced by general practice at a time when it is operating under increased pressure. However, we would strongly caution against the assumption that the challenges faced by general practice are caused by a lack of competition, or that the best lever to reduce perceived variability in access and/or quality would be an increase in competition.”

One of the most powerful levers described by the Report is “changing the operating model”.

“This lever is conceptually simple but often difficult to implement. For example, it often makes a great deal of sense to move physicians away from small (often solo) practices and into larger primary care practices or polyclinics (which include a wider variety of services, including diagnostics and outpatient clinics). Larger practices and polyclinics allow physicians to achieve economies of scale in some areas, such as administration. Furthermore, having a mix of physicians working together can improve quality and provide a more attractive working environment for new physicians (which might then help increase the workforce supply).

If a health system does decide to change its primary care operating model, it should consider a question even more radical than where physicians should work—it should ask whether certain primary care services need to be delivered by physicians at all. In the United States, for example, certain nurses with advanced training (nurse practitioners) are legally able to perform physical examinations, take patient histories, prescribe drugs, and administer many other basic treatments. Nurse practitioners can usually provide these services at a much lower rate than physicians typically can, but with comparable quality.”

This is a powerful summary, as it is consistent with the view that certain jobs can be better done by cheaper workforce. This is i itself a constructive idea potentially, simply in organising functions within the workforce for the people most suitable to deliver those functions. For example, many NHS hospitals have employed “physician assistants” to put in venflons or insert catheters, freeing up junior doctors to get on with other tasks in their busy schedule too. There comes a problem as to whether diagnostic services should be ‘liberalised’ on demand, i.e. so that the ‘worried well’ establishing their autonomy can pay to have their blood pressure checked ‘on demand’ if they want it. Provided that the equipment works, and the user of the diagnostic equipment does not use that equipment negligently, and that the investigation itself did not do any harm or damage, a regulator might not intervene, depending on the exact circumstances of course.

The second “big lever” is integration, described as follows:

“As we discussed earlier, GPs are typically responsible for coordinating with all the other health professionals and organizations (sic) that provide care for a patient.  Coordination is hampered, however, by the fact that few health systems have effective methods for ensuring that information is transmitted to the appropriate places. Ensuring that such communication takes place does not require that all providers be part of a single organization (sic). However, it does require that all providers commit to sharing information and coordinating care and that a strong IT system operating on a joint platform is available to facilitate data exchange. Payors can encourage this type of alignment through their contracting (for instance, by requiring the providers to report the same set of metrics).”

And there is still a hangover of the integrated healthcare model from the US health maintenance organisations. Here it is possibly more of a case of joined-up thinking in some different ways. Regulators should be mindful of referrals being made between primary care and secondary care (where VerCo GP practice refers to Verco NHS Trust) not on the basis of clinical need but for shareholder dividend, though the cases of clinical regulators making sanctions on the basis of unethical conflicts of interest are currently sparse for whatever reasoning.  It is also remarkable how keen and enthusiastic many corporates are on building the IT infrastructure for primary care, and indeed these noises of data sharing and paperless records are echoed by Jeremy Hunt. Ultimately, if one so wishes, whoever ‘owns’ primary care, whether it is a state-run service or not, this IT system could be ultimately linked to the private insurance system; a minority feel that that is where an aspect of integrated care is ultimately aiming towards.

The drumbeat from McKinsey’s and Apax is therefore providing a structural set-up and culture such that there can be a greater number of private providers in the holy grail of primary care. The notion that GPs are ‘only interested in their wallet’ (as famously said by Kenneth Clarke) is not at all borne out by the evidence from the professional bodies or regulators, and whilst there have been many touting GPs as businessmen (including some isolated opinions from the leadership of the Socialist Health Association (“SHA”) which have to be read in context, e.g. as in this recent blogpost by Martin Rathfelder (Director of the SHA)):

“The issue is blurred anyway as many GPs have found ways to “profit” through taking interests in companies providing services.”

People who do not hold the same views as McKinseys’ and Apax should be allowed to influence an incoming Labour government, whether they are or have been the leadership of the SHA or not. It is hoped that these alternative views do not merely act as a boring echochamber, and genuinely reflect the founding values of the NHS.