Will competition split consultants and GPs?

Will the Health Bill improve or kill off relationships between primary and secondary care? Abi Rimmer reports.

Consultants and GPs: will the Health Bill drive them apart (Photograph: SPL)
Consultants and GPs: will the Health Bill drive them apart (Photograph: SPL)

From the start of the listening exercise on NHS reforms, the government gave clear indications that GP consortia would be required to involve a wider range of health professionals.

The concession followed warnings from MPs and the BMA that they should encompass senior hospital doctors, medical academics, public health doctors and patients.

But will the Health Bill's efforts to drive up competition between NHS providers make it hard to maintain good working relationships between GPs and consultants? Past incentives, such as Choose and Book, have already had a negative effect on GP/consultant relationships, stripping GPs of the ability to refer to a named consultant.

Mr Stanley Silverman, consultant surgeon and West Midlands director of professional affairs for the Royal College of Surgeons, says the system removed the 'personal aspect' of the relationship.

Dr Ron Singer, president of the Medical Practitioners' Union, says: 'Under Choose and Book it has been impossible for GPs to build relationships with hospital consultants.'

Deepening the divide
Clinicians now fear competition driven by 'any qualified provider' - the policy formerly known as 'any willing provider' - will deepen the divide.

The BMA warns that 'NHS providers could be pitted against each other in an effort to attract patients and funding'.

Amendments to the Bill proposed by the BMA demand that 'consortia are not forced to promote competition between providers and instead are able to work collaboratively across primary and secondary care'.

GPC negotiator Dr Beth McCarron-Nash says: 'I can't see how competition can create collaborative working.'

Fellow negotiator Dr Chaand Nagpaul agrees: 'The greatest obstacle to collaborative working is the government's intention to create competition.'

He says the DoH needs to replace the 'payment by results' tariff, which pays hospitals a set fee for each episode of care they provide. 'It's adversarial,' says Dr Nagpaul. 'The government must provide incentives to get GPs and hospital doctors to work together.'

Dr Singer recognises there is a need to share data to improve quality, but warned that enforcing competition could 'wreck relationships'.

Despite the concerns, some GPs say competition may not be as damaging as it first appears. Dr Stewart Findlay, County Durham and Darlington GP and consortium pathfinder lead, says: 'Some consultants are worried about competition. But they don't understand the advantages of clinician-based commissioning.'

Dr Findlay says changes set out in the Bill will force GPs and hospital doctors to work closer together. 'In the past we were almost discouraged from talking to our consultant colleagues,' he says. 'The changes will push GPs and consultants and nurses to talk to each other.'

Clinical leaders group
Dr Darin Seiger, chairman of the Nene Commissioning consortium in Northamptonshire, set up a 'clinical leaders group' to encourage GPs and consultants to work together. He says competition will mean it is in hospitals' best interests to work with GP consortia. 'Hospitals need to ensure they have as large a market share as possible.'

Consultant Mr Silverman also says GP consortia are unlikely to bypass local hospitals when commissioning services, potentially making competition less of an issue. 'Any sensible GP will not want their local hospital to fall over,' he says.

King's Fund senior fellow Nick Goodwin agrees. In most parts of the country GP practices have a 'symbiotic relationship' with local hospitals and are therefore unlikely to look elsewhere when commissioning, he says. 'For most care there is probably no alternative than to collaborate with local services.'

But whether colleagues can collaborate successfully may ultimately depend on history, Mr Silverman suggests. 'Where there were good relationships before, colleagues will continue to work well together.'

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