The internal market is 25 next year. Like the passing of seasons, the growth of children, the counting of Christmases, it is an odd surprise to realise how much time has slipped by.
So much has changed! In 1990, Microsoft became the first company to achieve sales in excess of $1 billion. The Hubble telescope went into space. Tim Berners-Lee and Robert Cailliau at CERN proposed a ‘hypertext’ system that year, the former successfully setting up the first web server at info.cern.ch on 25 December and launching the internet as we now know it.
Launched in a fanfare, the NHS internal market started by making Health Authorities responsible for managing their own budgets.1 A large slice of the intention was to challenge the dominance of hospitals in the NHS economy. The unleashing of an entrepreneurial spirit among health authorities was helped along further the following year with the conversion of some into the first NHS Trusts.
Fundholding too followed in 1991. It was good for some general practices, the early wave fundholders in particular. For those who missed out, they often found their patients coming second to fundholders’ patients at the hospital door: seeing more fundholders’ patients became an obvious way for hospitals to increase their income.2
So many twists and turns in policy have followed since that giddy time, it is hard to remember them all, never mind the order in which they came. There have been so many in fact, it almost gives rise to the suspicion that those making policy doubt their success. Certainly, despite an endless cycle of ‘reform’, the dominance of the hospitals has grown further and the share of NHS resources going into primary care is at its lowest ebb.3
In the past 5 years, another development: the Care Quality Commission (CQC). This is a regulatory body designed for a market system whose services are not necessarily either publicly provided or quality assured.
It is a tacit admission that 24 years of contract management has not worked but without conceding that the internal market itself is the failure.
Recently, my new practice was inspected, the watchdog’s remit only lately extended into primary care. For reasons unknown, our part of Northumberland, huddled in the farthest north of England, was targeted: we were visited amidst a flurry of such visitations to practices in the locality. The experience did not inspire confidence.
And now one of us has been found to be unsatisfactory.4 Of course, it is not the only practice in this predicament nationally, but the questions it raises have resonance for all such cases. Questions that include many at the heart of those about the internal market since its inception. Questions like: can a provider be allowed to fail?
The politicians pulling the strings have not had the courage to allow hospitals to close. Even despite the recent travails at Hinchingbrooke, where the CQC has been very critical and the private provider, Circle, has decided to walk away, there seems little likelihood of closure.5 Primary care has no spare capacity either, but the politicians care less.
So, how to celebrate next year’s silver jubilee of the internal market?
- © British Journal of General Practice 2015