The government's invitation to supermarket chains and retail pharmacies to open up GP surgeries has provoked a generally negative response to what many doctors regard as ‘backdoor privatisation’. Yet, although this sort of political stunt seems unlikely to offer a future for primary health care, it does have the merit of challenging the current framework of GP services within the NHS.
When I came into general practice in the early 1980s, the small-shopkeeper model was still dominant. In the inner city areas where I worked, the corner-shop surgery often appeared to be a bastion of poor standards of practice in poor quality premises. For the radical Medical Practitioners Union (MPU), of which I was a rather inactive member, the independent contractor status of the GP was an anachronism, a consequence of the medical profession's reactionary resistance to the concept of the NHS and a bulwark of the sort of petit-bourgeois prejudices paraded every week in Pulse. At the time, I sympathised with the MPU's campaign for primary care services provided by salaried GPs in purpose-built health centres.
One of the ironies of the last decade is that, Although the socialist aspirations of the MPU have been crushed in the process of the wider collapse of the left, its vision of salaried GPs, collectivised in primary healthcare teams, has been largely implemented. Although I feel little regret at the demise of the lock-up shop, back-parlour, single-handed GP, his replacement by a state functionary committed to performance targets, lifestyle management and social engineering projects raises serious concerns about the future of medical practice.
The ascendancy of bureaucratic state control over GPs has thrown a new light on some of the virtues of self-employment. For example, the emergence ‘bottom-up’ of flexible, functional, computer systems in general practice owes much to its small shopkeeper traditions (while, in hospitals, records are still being trundled around in wheelbarrows and, of course, being lost). By contrast, the imposition, ‘top-down’, of government schemes like ‘choose and book’ has been another costly IT fiasco. While hospital consultants — and salaried GPs — are subjected to all sorts of managerial constraints, independent contractor GPs continue to enjoy substantial professional autonomy: despite increasing interference, we can still practice as we wish and say what we like.
Can Tesco or Boots offer a way forward for primary health care? I would not dismiss the possibility out of hand. They could certainly provide funds for capital projects on a scale that seems unlikely to be forthcoming from the public sector. The straightforward language of private enterprise would be a welcome relief from the cynical rhetoric of a health service administered by New Labour apparatchiks. Yet the notion that the supermarket can provide a ready-made solution to the exhaustion of the corner shop model of NHS primary care reflects the Blair government's simplistic approach to ‘modernisation’.
As numerous commentators have observed, health care is not a commodity that can be bought and sold like baked beans or socks. Choice among different brands is problematic enough for those shopping for consumer goods and services. When the consumer is ill and becomes a patient, what matters most is the relationship of trust that can enable them to negotiate the imbalance of knowledge and expertise in their encounter with a doctor. Out-of-town shopping malls will not provide easy access to healthcare professionals for the infirm or the elderly. The atomised interaction of the checkout counter will not be a satisfactory substitute for a continuing personal relationship of care, at least for those customers who need more than occasional travel vaccinations or hay fever remedies. There is some doubt whether many supermarket customers really want ‘24–7’ services; the attempt to provide health care in this way is destined to sacrifice quality and continuity to political expediency.
The history of primary care suggests that neither the market nor the state can guarantee the professional autonomy of the doctor that is crucial to the doctor–patient relationship. The spectre of supermarket general practice confirms only that both the small shopkeeper and the state socialist models of primary health care are moribund. The challenge is to find ways of funding and providing primary health care that ensure adequate resources while respecting the distinct, but complementary, interests of doctors and patients.
- © British Journal of General Practice, 2007.
