Thursday, 17 March 2011

The future of the NHS

Duck on the Badscience forums asked me to blog my concerns about the future of the NHS and how what we are about to see is wholesale privatisation.

What I was saying there is that GPs don't have the time, resources, or infrastructure to suddenly take over all the functions of PCTs next year while carrying on with their day jobs. So, naturally, they will be looking to contract out the commissioning function. But this is just one aspect of the overarching drive towards privatisation.

Something worth remembering when considering GP consortia is that these are consortia of GP practices, not individual GPs. And GP practices are no longer partnerships of equals but increasingly becoming small businesses which differ from the larger healthcare companies purely in size. The last Labour government introduced the idea that GP practices were not partnerships of GPs by removing the need for a certain number of GP partners for a given number of patients (or rather a given amount of money). Instead they were to be treated as small businesses contracted to provide GP services. This has lead to GP services being increasingly provided by salaried GPs (who are usually more recently qualified GPs) employed by the GP practices which are owned by GP partners (who are usually older GPs). Since these changes were brought in the majority of jobs available for newly qualified GPs are salaried positions and not partnerships.

So general practice has moved from being an ostensibly private but effectively collectivised system of equals (at least as far as medical staff go, the position of ancillary staff was different) to become a business like any other - the older generation of GPs have taken advantage of the new rules to become small businessmen increasingly acting as employers and screwing profit out of employees rather than acting as traditional family doctors while the newer generation of GPs become wage slaves. It won't be long before the traditional GP practice disappears (as the old partners retire and sell on their stake in the small business they own) as they are swallowed up by larger healthcare businesses - and then who is going to control the NHS budget? It won't be the workaday GPs who will just be employees of these big companies. **Poof** de facto privatisation.

The words of Liz Kendall (Labour) from the Commons debate on the upcoming NHS cluster-fuck (via Dr Grumble):
Our health and our NHS are not the same as gas, electricity or the railway. That the Secretary of State believes that they are shows how dangerously out of touch he is. What is the likely result? GPs will be forced to put local services out to tender even if they are delivering good quality care that patients choose and like; hospitals and community services will be pitted against one another when they should work together in patients’ interests; care, which as many hon. Members have said is vital as our population ages and there is an increase in long-term conditions, will become more and not less fragmented; the financial stability of local hospitals will be put at risk, and they will have no ability to manage the consequences of choice and competition in the system; and the whole system will be tied up in the costs of red tape, as GPs and hospitals employ an army of lawyers and accountants to sign contracts and fight the threat of legal challenge, huge fines and the potential of being sued. Let us also be clear that the Bill gives Monitor the same functions as the Office of Fair Trading, so it can fine organisations up to 10% of their turnover.

The more we see of the Bill, the more the truth becomes clear. The Secretary of State says that he wants clinicians to be more involved, and “no decision about me without me” for patients, but when the Royal College of General Practitioners, the Royal College of Surgeons, the Royal College of Nursing, the Royal College of Midwives, the British Medical Association or anyone else tells him that he should stop, think again and halt his reckless NHS plans, he refuses to listen. When the Alzheimer’s Society, the Stroke Association and Rethink tell him that his proposals will not give patients a stronger voice and improve public accountability, he simply tells them that they are wrong. When health experts such as the King’s Fund warn that driving competition in every part of the NHS will make it more difficult to commission the services that best serve patients’ interests, he simply puts his fingers in his ears and walks away. What makes this Secretary of State think that he is right when professional bodies and patient groups know that he is wrong?

Doctors and nurses do not support the Government’s plan, patients do not want it, some Conservative Back Benchers and members of the Cabinet do not like it, and the Liberal Democrats hate it. They had the sense last Saturday to see what the hon. Member for St Ives (Andrew George) called the potential catastrophe as far as the future of the NHS is concerned, and to ask for amendments to the Bill. I hope they have the sense to join us in the Lobby tonight.


Anonymous said...

You need to speak to some GP partners and salaried GPs. The vast majority are not in the exploitative relationships you (and many others) suggest, (did you all read the same Pulse article?) I've been both salaried and a partner and they are very different jobs with different responsibilities and not very different salaries. BMA T&C are v. good for salaried docs, but once providers are all APMS they may be able to apply their own T&C, and then there will be the exploitation you fear.

Paul said...

If GPs love the NHS, believe in its values, and strive to protect them (as they claim), then why would they act the way that you've described. Wouldn't they instead work in practices where all GPs are partners and only sell their partnerships to other GPs?

It's time for a bit of consistency guys! It takes more to protect the NHS than just claiming that you believe in it.

pj said...

I'm sure that the majority are not in exploitative relationships but I am hearing more and more about the frustrations of salaried GPs of my generation about the limited opportunities for career advancement and the rise of the salaried GP certainly seems to have seen a corresponding rise in GP small businessman.

But yes, when APMS becomes teh default contract model, which it eventually will, then that will be the end of traditional general practice.

pj said...

There are plenty of good reasons for waning a salaried job - avoidance of management roles, flexibility to work part-time or to move on, but I'm increasingly hearing from GP partners that they like salaried jobs because they're cheaper and don't dilute equity share, the employees are easier to sack, and they're easier to boss around.

Worth noting that it isn't just APMS providers (incidentally, another Labour 'innovation') that are looking to have all the benefits of being an employer of salaried GPs with none of the downsides:

"Meanwhile, a recent Pulse survey of nearly 50 salaried GPs, carried out in conjunction with the National Association of Sessional GPs, found 14% of salaried GPs in GMS practices did not have their contracts based on the model contract. Predictably, the picture was even less rosy in PMS practices, with just 52% of salaried GPs on the model contract. The survey also uncovered a big pay gap between salaried GPs who were on the model contract and those who weren’t."