The white paper: contest for contracts

Julian Tudor Hart

As David Jewell says, the White Paper assures us that tendering processes for provision of primary care in underdoctored and oversick areas will be fair.1 What evidence is there to support this assurance?

The first serious contest for such contracts took place in December 2005 at Langwith and Creswell in North East Derbyshire, communities socially devastated by the destruction of the British coal industry since 1985. Dr Bess Barrett, with 20 years' experience of providing care in the area, a good clinical team with university connections, unanimous support from local councillors and development land offered free for a new building, submitted her imaginative plans for provision of care after wide consultation with local people and their elected representatives. I know what it's like trying to find staff willing to accept the huge workloads and small material rewards of good practice in mining areas. A primary care trust genuinely representing the interests of the people it is supposed to serve would have needed to look no further, and been grateful to know that miracles may still occur.

In the event, Dr Barrett's bid was not even short-listed. The preferred bidder was UnitedHealth Europe (UHE), UK division of the biggest commercial provider of primary care in US. Its director is Dr Richard Smith, former BMJ editor and one-time opponent of a commercialised NHS. Its president is Professor Simon Stevens, former chief adviser on NHS policy to the prime minister. They had no staff yet recruited, no plans for their own premises, and no visible support from the communities they proposed to serve. Through the Freedom of Information Act, Dr Barrett learned of the main criteria on which this selection was based: past experience of providing primary care; past experience of interaction with consumers; back-up resources, especially expertise in information systems; and ‘strategic vision’. As this was UHE's first venture into the NHS primary care market and it had done nothing to ascertain local opinion, it should have scored zero on the first two of these criteria, but in fact it scored highest of all bidders. This can be explained only if the trust accepted experience in the US market as equivalent or superior to experience in the NHS. As for resources, if bids are to be judged simply by the size of their managerial staffs, bank balances and shareholders, we have evidently seen the last of any GP providers of care in post-industrial areas. And ‘strategic vision’? This was presumably matched against visions revealed to Prime Minister Blair in his personal discussions with God.

Fortunately, the Trust's decision is still subject to judicial review, initiated by local Labour councillor Pam Smith. A judge ruled recently that selection of UHE must go on hold until a decision has been reached on its legality. As we await this verdict, we need to understand that so far as government is concerned, the era of civilised discourse and restrained civil conduct is long past. Lying to the public for its own good is permissible to people with power now, as once it was for our formerly autocratic profession. In the UK as much as the US, we are now ruled by fundamentalists, whose faith in market competition and the profit motive as the sole path to effective public service is unshakeable by evidence.

David fought Goliath on a level playing field, knowing that he must fight to win, which means having some idea what to do next. We also can quote scripture, and hopefully think beyond it.