Government ‘reforms’ to primary care have shifted professional control away from general practitioners and financial control away from government, argue senior doctors in this week’s British Medical Journal (BMJ).
The changes raise important questions about public accountability, they warn.
Since 2003 the UK government has created a market in primary care, write Professor Allyson Pollock and colleagues.
This means that general practitioners are no longer contracted directly to the NHS and primary care services can now be purchased from corporate contractors using commercial contracts.
The changes gave primary care trusts in England, health boards in Scotland, and local health boards in Wales new powers to negotiate contracts with commercial companies.
Many of the changes to regulation were intended to facilitate the entrance of new providers to the healthcare market.
In March 2007 about 30 companies held commercial contracts to provide primary care services in England through their ownership of 74 health centres and general practices, excluding out of hours contracts (table). The companies comprise general practitioner owned and operated companies; international healthcare corporations, including drug companies; companies with commercial links to the drug industry and healthcare corporations; companies providing catering, cleaning, and laundry services under private hospital contracts; and some joint ventures between these.
The authors warn that decisions about services have shifted from general practitioners to contractors.
General practitioners’ professional control over the range and provision of primary care services has been substantially reduced.
Before the reforms, doctors were contracted by the government to provide ‘all necessary and appropriate medical services of the type usually provided by general medical practitioners.’
The primary care market is premised on the break-up of the general practitioners’ monopoly of the provision of primary care.
They explain that from 1948 until 1997 GPs were contracted to work for the NHS under a general medical services contract between the secretary of state and the individual practitioner, on terms negotiated nationally.
The contract was set out in the provisions of the Red Book, an extensive set of guidelines and regulations covering range and quality of services, staffing, and premises.
The national contract was broken in 1997 by the introduction of personal medical services contracts, which allowed local negotiations between general practitioners and commissioners about service specification.
In 2003 the Health and Social Care (Community Health and Standards) Act ended the general practitioners’ monopoly over the provision of primary care to the NHS, allowing primary care trusts to commission care from ‘anyone capable of securing the delivery of such services.’
The national agreement under which general practitioners were contracted directly to the secretary of state for health was replaced by four contracts:
• A new general medical services contract between practices and trusts
• An alternative provider of medical services contract5
• A locally negotiated personal medical services contract
* A primary care trust medical services contract enabling trusts to employ general practitioners directly on salary.
General practitioners no longer have a direct contractual relationship with the state because the contract is between the practice or the company and the primary care trust.
The authors warn that contractors may also determine the way in which services are delivered and determine, ‘in their reasonable opinion,’ when home visits take place, when out of hours services are offered, who is removed from patient lists, and which serious incidents relevant to a contractor’s performance are notified to primary care trusts.
Furthermore, the new system allows for contractors to manage specialist services formerly provided in hospitals but moved out into the community.
Pollock and her colleagues stress that commercial contracts have implications for service planning, public accountability, access to health care, and government control.
Market forces have also changed the legal basis of service provision and have replaced government regulation as the principal regulatory control.
This allows alternative providers considerable freedom with respect to staff terms and conditions and the way in which care is provided.
The change from professional regulation and direct government control to commercial contracting has been introduced in advance of a system to regulate the new market, which was only being consulted on in November 2006.
The Department of Health proposes that market forces should be the principal regulatory control on contractors.
The authors warn that the introduction of practice based commissioning gives contractors budgetary control over a wider range of services.
Contractors can hold the NHS budget not just for primary care but also for acute hospital care and community services, making them both gatekeepers to and budget holders for services.
Also, contracts with limited liability companies mean that the NHS cannot obtain redress beyond the value of the company’s shareholding if the company fails to deliver on its contracts or becomes bankrupt.
The NHS commissioner has no recourse to other assets or income of the shareholders.
The Department of Health proposes that management of financial performance will not be extended to privately owned providers but will be the responsibility of ‘their owners/trustees/shareholders.’
The authors warn that recent inquiries by the National Audit Office and the House of Commons public accounts committee into out of hours services and the consultants’ contract suggest that primary care trusts and the Department of Health have insufficient information and knowledge to negotiate clinical care contracts.
Finally, Pollock and her colleagues argue that the introduction of commercial contracts will see the jurisdiction for healthcare policy and law move away from national government to the European Union, even though the EU’s mandate is trade and commerce and not public health.
The government has allowed more firms to provide NHS funded primary and community care because it believes that competition will improve the public health, write the authors.
But nothing is yet known about the consequences for access, costs, quality, and accountability.
It is surely time to evaluate the policy, they conclude.