‘One of the best bits of the NHS is primary care.’ That's my first response when asked by people abroad what I think of the NHS. There is lots of evidence to support the statement, and I doubt that many BJGP readers will dissent. ‘But,’ I would sometimes add, ‘the problem with primary care in Britain is that it generally works best where it's least needed. The most deprived people generally get the poorest services.’ There are of course glorious exceptions — and Julian Tudor Hart, who is upset by what he sees as my Faustian conversion1 — provided one of the most outstanding.
But the evidence in primary care to support Julian's inverse care law is overwhelming — what's more the inequalities have been there since the NHS began.2 They have probably worsened. I remember writing a BMJ editorial in 1981 on the Acheson report on the severe problems of primary care in London.3 Charles Booth's map of poverty in London in 1899 looks remarkably similar today.4 Indeed, the traditional model of general practice is collapsing in some of the poorest parts of the country, and primary care trusts are struggling to cope. They are not well equipped to run general practices and need help.
Sadly, the NHS has failed in nearly 60 years to achieve its compelling vision of abolishing inequalities in health and providing equal quality care for all. It's surely time to try something different, and let's avoid ideology standing in the way of practical solutions. Nobody in the political mainstream wants, however, to abandon the fundamental principles of the NHS: universal coverage, free at the point of access, driven by clinical need rather than ability to pay, and equal quality care for all (the last sadly an aspiration still). Certainly I do not want to abandon those principles, and nor does UnitedHealth Europe, who I work for. If those principles are abandoned we have failed as a company. In contrast, if the private insurance sector implodes we will have succeeded.
So the different response has to be within the NHS, and this is one reason for the appearance of ‘alternative provider medical services contracts.’ Let's see if new organisations — voluntary sector organisations, social enterprise companies, private providers, and others undreamt of — can succeed where traditional general practice has failed. This isn't so shocking because, as Julian well knows, most GPs are themselves in the private sector.
I think that the new possibilities can make a difference and begin to solve these long-standing and shameful inequities. That's why I joined UnitedHealth Europe. We are already beginning to see evidence of change in primary care. The practice in Cresswell and Langwith, that Julian refers to,1 was first tendered 3 years ago. There were four expressions of interest. This time there were 48, and 20 organisations, including groups of GPs from other parts of the country, submitted bids. Two years ago there was no press coverage of the plight of these deprived communities. Now there have been over 20 pieces, many of them in the national media. The nation's attention has been drawn to this unfashionable problem. I think that new arrangements and new organisations may be able to make a real difference.
I know that Julian and other longstanding friends are perplexed by my move to UnitedHealth Europe. They fear the basest motives: I've taken the Yankee dollar. I see it very differently. I think that I've been presented with an opportunity to make a real difference, to help keep the NHS alive and counter inequalities in health — not just through primary care but also though enhancing the commissioning of care, improving the care of patients with long-term conditions, and providing much needed information tools to the NHS.
We work exclusively within the NHS in Britain, and ultimately it's for the NHS to decide if we bring benefit. If we do, we can flourish. If we don't, we'll be gone — and I can perhaps spend an afternoon sailing with Julian, a man I greatly admire. Maybe I can even if we succeed.