"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Tuesday, 1 November 2011

GP Market

There was a short piece on the Today programme yesterday (here at 52m52s, also on the BBC website here) where journalist Jane Dreaper interviewed Sir David Nicholson. There wasn't much discussed, but the following was interesting.

Sir David said that under the Health Bill data will be provided about what services your GP provides compared to other GPs in the area and nationally:
"this is a powerful mechanism for patients to make choices about which GP they use - if you have a long term condition you might want to think in the future about different GPs and whether they are providing a full range of services"
There are a couple of issues that Sir David is ignoring here. First - it should not be necessary to say this, but clearly Sir David seems to have forgotten - a long term condition (LTC) is 24x7 and it is usually for life. A patient will die with the LTC and most likely will die of the LTC. This makes continuity of care vitally important. The best control of their condition comes when patients with LTCs have a good and continuing relationship with their care team. The idea that patients can simply "shop around" for services means that such relationships will be difficult to form and maintain and this threatens continuity of care. Jonathon Tomlinson has written extensively about the relationship between GPs and their patients and Sir David could do no better than to read his latest blog.

Then there is the issue of how will patients know what services could be available? Occasionally I attend diabetic support group meetings and it is clear that there are some people who have had diabetes for decades and are still treating it like they were first taught to. Their blood tests show that their control is adequate so there is no need to tell them to do things differently. If a patient is treating their diabetes like it is 1980, they will not know if their GP is not providing all the diabetic services they should. It should not be the responsibility of the patient to move to a GP with the best services, it should be the responsibility of all GP practices to provide all the necessary services.

The final issue with Sir David's comment is that it appears to ignore the structures that he is putting in place. Every GP has to be part of a Clinical Commissioning Group (CCG). The Health Bill says that CCGs have the responsibility to ensure that healthcare services are provided for the patients in the area that the CCG covers. This is important: it is a responsibility of the CCG that the GP practices in the group provide the services that are required for their patients. So if a GP does not provide a service that will be as much the responsibility of the CCG as the GP. To get the service the patient needs, s/he will have to move to a GP practice in another CCG that supports the service. There are some large CCGs (for example the Manchester CCG has 107 GP practices, Liverpool has 91, County Durham has 88) so moving to another GP in another CCG will mean having to change to a GP in another city. That is simply not possible for most patients and certainly not possible for patients with long term conditions who need a continuity of care.

Sir David was suggesting a market of GP, but he has structured the NHS so that this is not possible.

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