Competition, choice and quality in general practice

The evidence in favour of using competition between GP surgeries to improve the quality of patient care rests almost entirely on a 2010 report by the Competition and Cooperation Panel, a so-called: Empirical analysis of the effects of GP competition. This showed that GPs with neighbouring practices less than 500m away made fewer referrals for certain conditions and had patients who were 0.1 percent more satisfied than patients from practices without such close neighbours.

I have lived and worked as a GP in densely populated urban areas with many close, neighbouring practices for the last 12 years and so I read with interest and dismay a blog written by entrepreneurial doctor Neil Bacon on the website of one of the most respected health think tanks, The Nuffield Trust.

Bacon concluded, much like the authors of the paper, unambiguously and without criticism that, ‘everyone who truly believes in improving patient care should be arguing for increased and fully regulated competition in primary care. Fact.’

There are many problems with the CCP report, not least are the difficulties in defining quality in care, explored in detail at a recent conference I attended at Cumberland Lodge, and in brief in the British Journal of General Practice. My own practice has roughly a 30% turnover of patients a year with a list size of 12 000 patients, so over 3000 patients leave and join our practice every year. This is not unusual in inner city practices. I ask new patients why they join us. Quality, whatever that means, is not the same as ‘what matters’. What matters to a family with young children, is very different to that of a housebound elderly man with a complex neurological disorder, a busy businesswoman with an endocrine disease requiring regular monitoring or a patient preparing to undergo gender reassignment.

In my experience neither the patients I speak to, not the GPs I know behave in the way that the authors of the paper, or Bacon, assume. Nowhere in the 51 pages of the CCP paper do the authors study how, or even whether patients are choosing, or GPs are competing in the manner they imagine.

There is a contrast between the traditional model of medicine as a vocation, health care as a public good and the sick patient as a vulnerable citizen who has a right to care (and for whom the clinician has a duty of care) and a new era of market values where medicine is a business, health care a transaction and the sick patient a customer.

The formulation of the patient as a ‘rational chooser’ underpins contemporary political policy, but is contradicted by studies about the experience of illness, the nature of suffering, the practice of care and the wishes of patients.

Most of my time as a GP is bound up in therapeutic relationships with patients who have multiple, long-term conditions and/or mental health problems. That this is the case for my practice which has a younger than average patient population, suggests that for the majority of GPs with a greater proportion of older patients this is typical of even more of their work. One of the commonest questions new patients ask is, ‘will you be my doctor?’

Relationships between doctors and patients are built up over time and involve trust and commitment on behalf of both parties. Because of the investment in time that this takes, patients are loathe to leave a doctor that they trust, even if they suspect he might not be the best doctor around. Counter to the claims of competition and choice advocates, the importance of continuity of care is being recognized as being fundamental to the safe and effective management of patients with complex multiple conditions and even in our practice, where we have 14 doctors, none of whom work more than 7 clinical sessions a week, we have made continuity of care a priority and are succeeding in making sure that every patient has their own doctor.

From the perspective of most patients, a doctor who they have gotten to trust and that knows them is more tangible and therefore valuable than some abstract notion of ‘quality’.

Fortunately for patients, doctors are motivated by a wide range of factors of which a deep understanding of what needs to be done to deliver high quality care, a culture of commitment, supporting colleagues, and education are the most important.

The introduction of clinical commissioning groups (CCGs), although greeted with great scepticism because GPs are being scapegoated for the failings of the NHS reforms, is resulting in renewed enthusiasm for these intrinsically collaborative activities. Unfortunately the funding for our CCG is only 40% of the funding that was given to the PCT (the Primary Care Trust that it replaced on April 1st 2013). My own experience is that commitments to my patients and medical students doesn’t permit me sufficient time to devote to the CCG. The future of many, if not most CCGs hangs precariously in the balance.

I believe that patient choice demonstrates that we as doctors treat our patients with dignity and respect for their values and opinions, as partners, willing and able to share decisions about their medical care. As conceived by the proponents of competition, patient choice has nothing to do with this, but instead it is to be used as a tool to promote a medical market using patient feedback websites, the like of which Neil Bacon promotes. Competition and choice risk increasing inequalities because GPs seeking to maximise their income may design services to satisfy those patients most capable and likely to exercise choice by changing practice – the young and healthy rather than the housebound, seriously ill or impoverished who need most care. Providing a minimal service to a large patient list remains one of the most profitable tactics of unscrupulous GPs.

It is both futile and inappropriate to make patient choice the servant of a medical market place and a tool for quality improvement, especially on the basis of such poor understanding of the complexities of patient choice and the quality and nature of patient care.

A shorter version of this blog is due for publication on the Nuffield Trust website today.

See also: Competition in the NHS: Is the toothpaste out of the tube? Blog by the founding director of the Competition and Cooperation Panel

Courtesy of Jonathon Tomlinson at Abetternhs’s Blog