‘“When a man walks into your office, sits down in front of your desk, and tells you that he is Napoleon Bonaparte, do not get drawn in a discussion of cavalry tactics at the battle of Austerlitz” … They conceal the central point. The thing is mad.’1
When private providers argue why they are good for UK primary care, we need to consider not only their ‘cavalry tactics’, but also the possibility that there is something inherently unsound about what they propose.
The main opportunity for private providers to gain access to the NHS tends to be practice vacancies, both real and manufactured, in deprived areas. An argument has been developed, therefore, that private providers have a particular contribution to make in such areas, delivering high quality care and narrowing health inequalities. While a little rhetoric appears to go a long way in securing NHS contracts, the claim merits inspection. What is it about private providers, and their understanding of the problems of primary care in deprived areas, that justifies support for their approach?
The continuing inverse care law comprises an old problem and a new problem.2 The old problem is that a flat distribution of medical and associated manpower in primary care is insufficient to address the burden of health problems in deprived areas, which is 2.5–3 times greater in the most deprived tenth of the population than in the most affluent tenth.3 With more cases and less time, the circle can only be squared by leaving many things undone. A culture of low expectations has evolved.
1948 solved one type of access problem, providing everyone with access to a GP, and via that route, to hospital services. That coverage was, and is, a huge social achievement, albeit with larger list sizes in deprived areas. But with some important exceptions it is no longer the principal problem of access in the NHS. Patients don’t just need to get in the front door. They also need to get through the building and out the back door with everything the NHS can do to improve their heath. What matters is access to outcomes.
As a result of the large number of clinical interventions of proven effectiveness, population approaches to preventive health care now have an important effect on public health and may be the principal determinant of increasing longevity in developed countries.4 The new problem is that if these approaches are delivered more effectively by primary care in affluent areas than in deprived areas, the NHS becomes a driver of widening inequality.
The original mismatch of need (the ability to benefit from health care) and resources is compounded, when the NHS faces not only the traditional challenge in deprived areas of increased levels of demand, via routine consultations, out of hours care and emergency hospital use, but also the modern challenge of improving public health, via population approaches to risk reversal and the prevention of complications. The coverage rates that these approaches require are much more difficult to achieve in deprived areas.1
The flatness of primary care is like a swimming pool (Figure 1), in which everyone who can be seen has their head above water, but while practitioners in affluent areas are standing in the shallow end with their feet on the bottom, practitioners in deprived areas are in the deep end, treading water to breathe. All practitioners are busy, but they are busy responding to different types of patient demand. Affluent patients want more time to discuss their problems. Deprived patients need more time to address unmet need. A central issue is the high prevalence of patients in deprived areas with complex health, social and psychological problems.2 Most of this is familiar to professionals working in the front line, but for many outside primary care it is a foreign country.
Comorbidity is commonplace in deprived areas, but an exclusion criterion for most clinical trials. The care of such patients is not helped by the increasing fragmentation of the health service, the compartmentalisation of roles (including GPs with special interests) and the profusion of vertical care programmes, which providers are encouraged to provide, but which cut across the generalist function. What patients with comorbidity most need is a continuing, personal relationship with a practitioner, who could be an exceptional nurse, but is much more likely to be a doctor.
The neglect of general practice in deprived areas has allowed some wild flowers to bloom, such as Julian Tudor Hart and Sam Everington, but these are exceptional individuals and while their examples show what is possible, they do not solve the problem of how such services can be delivered across the board. For many, probably the majority, the commitment of these pioneering doctors goes beyond the call of duty.
There is no evidence that choice between competing providers is what patients want (they are not ‘customers’ who want to shop around), or that this approach provides a mechanism for solving the problems described.5 Patients in all areas generally want the same thing
— a doctor whom they know, who will tune in to their situation, help sort out their problems, be there for them when they return, and who will not short change them in terms of access to effective health care.
What patients in deprived areas also want and need is that their carers should be able to do more. They have not been helped by a new GMS contract, which rewards larger practices more highly than small practices for achieving the same targets and, thus, systematically disadvantages the majority of practices serving poor areas.6
Health care is a lucrative business, which is why there will always be commercial companies and their front men, seeking to provide solutions to the health service's problems. One can see how they provide an attractive solution for policy makers and NHS managers trying to fill gaps in service provision in deprived areas, but filling gaps is a limited objective, and the real test, assuming additional resources, is for the NHS to be at its best where it is most needed.
Will the doctors and nurses hired by private companies, and primarily accountable to them, have the long-term commitment, flexibility, and ablility to develop the relationships of collaboration and trust, on which health improvement in primary care depends?
The health service can no longer rationally review services for hip surgery, because of the large, unknown number of procedures carried out in the private sector. Will similar black holes now appear in the information base for primary care?
How is it supposed that the problems of primary care in deprived areas, most of which stem from inadequate resources, are best addressed by an organisation whose modus operandi includes taking resources out of the system for the benefit of its shareholders? Surely this is the most fundamental difference between private companies and other NHS providers.
The status quo is not an option, because it leaves the NHS as a driver rather than a narrower of health inequalities, but if private companies are considered to be the solution, we need a much wider debate about the nature of the problem. We need to be sure that politicians are not repeating the mistakes of the Private Finance Initiative, solving short term problems while saddling the NHS with liabilities and constraints that will last a generation.
The front men of private companies ask us to believe that leopards can change their spots, or at least that predators need not be feared, provided they are kept in a cage, inside the NHS, with appropriate contracts and responsibilities. I am reminded of PT Barnum, the inventor of the three ring circus, who also pioneered a side show to which the public flocked, comprising a lion, a tiger, a bear and a lamb, all sharing the same cage. The exhibit worked best when the lion, the tiger and the bear had been fed, and were no longer hungry. When asked how long he hoped to maintain the exhibit, Barnum replied, ‘For as long as I can get a supply of lambs’.
- © British Journal of General Practice, 2006.