Filed Under (BMA, Competition, GPs) by Paul on 18-05-2011
This post continues my interest in the role that leading organisations in the medical profession have in trying to persuade the Government to come out against competition and especially the introduction of new entrants into the NHS.
If the BMA really believed in their position of being both against the private sector providing services and competition, there seem to me to be a number of powerful things they could do. The first would be to ban their members from taking part in private medicine. By this single action they would greatly restrict the impact of the private sector on British health provision, thereby advancing a policy they favour.
Why do I think that they will not do this?
Because a large number of their hospital consultant members would leave the BMA rather than lose their income from private health provision.
These members tolerate the bizarre stance that the BMA have taken against the private sector because they know it will have no impact upon their private income. They know that the BMA stance is against new competition that will shake up their earnings from private health. So it’s a sort of qualified dislike of capitalism. “We like it enough to make a lot of money out of it, but we don’t want to allow new entrants into the market upsetting our monopsony position”.
The same is true of their stance on primary care. The BMA could make a massive attack upon the free market in the NHS by suggesting that all GPs become salaried state employees. At one stroke they would deny the possibility of small business interests impacting on the NHS through the myriad small businesses that are GPs. If they really didn’t like the private sector having a role in the NHS, this would be a devastating blow.
Why do I think that they will not do this?
Because a large number of their GP members would leave.
So given the BMA could bring the private sector interests in the NHS to its knees and won’t, what are they trying to achieve with their policy against private sector work?
What they are trying to achieve is to stop any changes in the cartels their members are working with at the moment. They want the benefits from their current private sector experience without having the bother of dealing with new entrants that would create new ways of working. What worries them about competition is that it brings challenges from outside – challenges that must be met.
To meet that external challenge you have to change the way in which you work to come into line with new and better practices introduced by the external source. Or you don’t and give customers the opportunity to choose between your and the new way of working.
The interesting thing is that we actually have some evidence of the way in which GPs operate when competition moves into their locality.
In August last year one of the staff of the Co-operation and Competition Panel, Dr Chris Pike, published a paper which carried out an empirical anlaysis of the impact of proximity and competition on GP quality.
The full paper can be read here.
The abstract makes interesting reading.
An Empirical Analysis of the Effects of GP Competition – Dr. Chris Pike
Co-operation and Competition Panel August 2010
We analyse the relationship between the quality of a GP practice in England and the degree of competition that it faces (as indicated by the number of nearby rival GP practices). We find that those GP practices that are located close to other rival GP practices provide a higher quality of care than that provided by GP practices that lack competitors. This higher level of quality is observed firstly in an indicator of clinical quality (referrals to secondary care for conditions that are treatable within primary care), and secondly in an indicator of patient observed quality (patient satisfaction scores obtained from the national GP patient survey). The association between increased competition and higher quality is found for GP practices located within 500 metres of each other. However it would appear that the magnitude and geographic scope of the relationship are constrained by restrictions upon patient choice. As a result the findings presented here may only reflect a fraction of the potential benefits to patients from increased choice and competition.
The point made in that last sentence is important in looking at how a bigger impact could be developed by allowing greater patient choice of their GP.
One of the interesting issues that was revealed when the 60th anniversary of the NHS was celebrated in July 2008 was the uncovering of the first NHS leaflet that was delivered to every house in July 1948. When you turned over the first page, the very first thing that citizens were enjoined to do when they entered the NHS was to “First choose your GP”
This initial injunction always surprised me because I had fallen for the mistaken idea that the opponents of choice in the NHS had always promoted. They seemed to say that choice was a recent arrival in the NHS, and that in the good old days between the 40s and 60s choice had been anathema.
It transpires that this is untrue. Choosing your GP was there right at the beginning of the NHS.
What we now need to do is to resurrect the aims of the founding fathers of the NHS and recreate that choice for patients – to choose their GP.
In some places that choice is hard to make real. Given the minimum income guarantee (where GPs below a certain minima do not lose income when their registered population drops beneath a certain level) if patients do manage to choose a different GP, the GP may not experience any loss of income.
In most other walks of life this would be seen as really inefficient and wasteful of public money. We will go on paying for patient X even if patient X does not want to be registered with you.
As the above abstract says “the magnitude and geographic scope of the relationship are constrained by restrictions upon patient choice. As a result the findings presented here may only reflect a fraction of the potential benefits to patients from increased choice and competition.”
It must surely be right that citizens are free to choose their GP.
It must surely be right that unselected GPs are not paid for working with citizens who do not choose them.