View from the left: Primary care at scale could open door to insurance-based NHS

No doubt your CCG has been as preoccupied as mine with creating a federation, or a series of private companies or a network of practices.

This can involve huge amounts of work and resources – but is it worth it? Will it improve care? What are the risks? There is a rush: is it lemming-like?

At the same time new models of care are taking shape: the multispecialty community providers (MCPs) and primary and acute care systems (PACS) models in NHS England's vanguard scheme. These also create larger organisations, either formally or as larger organisational units, both methods bringing together different sectors.

Federations seem to offer continuation of the small business model - protection against an increasingly hostile world. One of the driving forces in our CCG has been fear that practices will be picked off one by one by private companies. Federations as companies in their own right will be able to bid for services in competition with others like Virgin. Join them, and try to beat them.

Obviously the key question ought to be not the commercial resilience of the business model but the impact on care quality. Some limited evaluation has already begun but this appears only to show that the ‘new’ models of care were already happening before they got the boost of vanguard status.

For genuinely new ideas in each case there has to be a proper transparent evaluation (by independent experts) of the case for change. Then, if the change is approved, of the real benefits of implementation. Only if this is in place should these experiments be endorsed. No doubt links between practices should enable better care with judicious management.

New models of care

Of course the background is the reality of huge underfunding and deteriorating quality across the whole of care, and we cannot go on ignoring the need for solutions bringing social care into the thinking. While these new models may well improve quality of care (otherwise why allow them?), they will not make any contribution to the ludicrous plans for £22bn of cuts.

My last View from the left column emphasised that the funding gap is the most serious threat to patient care. But these coalescences involving GPs have their own risks too - totally unnecessary risks.

The government, having spent £3bn pounds on a pointless redisorganisation, has left a legacy in law that enables privatisation of clinical services. And to fight that, CCGs and practices have had to spend fruitless hours creating more privatised vehicles to compete in that market.

At the same time, PACS and MCPs as they grow and coalesce, also open up opportunities for the private sector to offer not only backroom but clinical services as new contracts are set up. Monitor’s procedures make it very difficult to avoid tendering new or lapsing contracts on the open market. The market spreads its tentacles.

A further threat to stability is that the evidence of mergers and similar ‘market’ transactions within the NHS suggests it is a bad idea that never delivers what is claimed. We have ample evidence of this in my area of south-east London. Size matters, but not much.

GP practice takeovers

As these conglomerates become bigger, they may become more attractive to the private sector. Individual practices are the Little Billy Goat Gruff of the market - nobody wants to eat them. But federations and MCPs may well be a different matter. And the Monitor/Health and Social Care Act-driven process makes it far more difficult to butt the troll over the horizon.

So the first big risk is that the market obsession spreads.  All the evidence shows the experiment with markets in the NHS should be ended – it does not work. View from the left  made clear earlier this month why a market in clinical services is bad for patients and for the NHS.

The intention is for these larger organisations to become accountable care organisations. These will provide and plan for services across a wide area, making CCGs redundant. They are similar to American health maintenance organisations, independent financial entities far more easily run and controlled by insurance companies.

In summary, federations and new models of care may improve care. Let’s hope so. But the risks include:

  • More opportunities for the private sector to enter the community care market
  • More opportunities for the private sector to buy general practice
  • CCGs becoming redundant, just as they are getting into their stride
  • A final design shop-ready for insurance-based healthcare.

Practices need to make sure that as they come together to work with other organisations, they retain their contractual independence to avoid being open to takeover by large corporations.

  • Dr Brian Fisher is a semi-retired GP in south-east London and honorary vice-president of the Socialist Health Association. This column is a left-wing primary care perspective on health, social care, public health and healthcare – issues that matter to us and our patients. Some contributions will be from other authors. We hope to offer solutions as well as highlight problems.

Photo: Dan Wootton

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