I read the exchange between Julian Tudor Hart and Richard Smith with interest. Like Richard Smith, I too have been challenged by the writings and the example of Julian Tudor Hart. My approach to ‘making a difference’ has been somewhat different.
In 2004 I approached the Sunderland Teaching PCT (TPCT) to realise an ambition to take on a struggling practice in a needy area and turn it around. I worked as a locum in two such practices, one of which had been without a GP of its own for over 2 years. The team was superb and I joined them in November 2004 and was soon joined by a GP colleague. Together we set about transforming the practice. We were approved as a GP training practice with our first GP registrar in August 2005. Our QOF points for this year are 1047.
My declared intention was always to take on the management of the practice which was endorsed by the TPCT. This was partly in recognition of the difficulties they had faced managing GP practices from a distance with teams inevitably operating with considerable autonomy. In June 2005 we indicated our readiness to become a GP-led independent practice and the TPCT were happy to approve this move to independence, although it decided to advertise the practice.
We were confident we could prove our worth against other bidders for the contract, but became increasingly concerned that we might not find ourselves in a level playing field. We knew that individuals within the TPCT were themselves developing a business interest in the practice. Although we expressed these concerns to the TPCT we were told this would be an open, transparent and defensible process.
We had followed the Creswell situation. We were already concerned that the large commercial firms may have an unfair advantage over small GP practices. With their business experience and financial clout we feared a loss-leading bid the TPCT would find hard to refuse on the basis of value for money, reinforced by the choice of UnitedHealth Europe at Creswell.
The Sunderland TPCT resolutely affirmed they were under no external pressure with no incentives or targets to introduce alternative providers. It is our understanding that it was within the ‘gift’ of the TPCT to award this contract to the current provider. They expressed concerns that they could be subjected to a legal challenge under European Procurement Laws if they did not go through competitive tendering, although they now seem to accept that health services are largely exempt from this legislation. They seem unable to accept that maintaining the high quality care we have managed to re-establish would itself justify choice of the established provider.
Introduction of alternative providers is justified by PCTs as a means of filling gaps in service provision. In this situation there is no gap. We are amazed that our PCT seems willing to jeopardise the high quality health care that is provided to their patients and risk alienating the staff who have loyally provided care for these patients. If a ‘for profit’ organisation were to take on this practice it would inevitably result in the loss of the GPs and most of the staff who do not want to be managed at arms length by another organisation, driven by necessity to make profit for shareholders or directors.
Our patients have become aware of this situation and have given strong representation to the TPCT that they wish to keep their current GPs. In 2 weeks they obtained 1200 signatures on a petition from an all-ages list size of 3800. The TPCT claim that this support arises from inevitable bias toward established GPs—a remarkable comment in the context of a ‘patient-led NHS’.
The TPCT has agreed to review this process but the indications are that they will press on with advertising the practice and expose us to the vagaries of the market place. We wait with interest to see if Richard Smith, John Chisholm and Simon Fradd or a local ‘for profit’ GP consortium bid for this practice. Maybe they do envisage making something good, better, but I suspect that business is far more prominent in their minds.
When I joined this team I became a salaried GP and took a significant drop in income but this has been more than compensated by the sense of ‘making a difference’ in this challenging situation. It is with a real sense of betrayal that I have seen the TPCT choose the option to advertise the practice. If UnitedHealth Europe is allowed to take on the contract, this will turn to outrage, not diminished by Richard Smith's declaration that his huge organisation will leave if it fails to benefit the NHS.
- © British Journal of General Practice, 2006.