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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 June 30; 334(7608): 1349.
PMCID: PMC1906656
Body Politic

Collision, collusion, and confusion

Nigel Hawkes, health editor

Choice for patients, localisation of services, and practice based commissioning—can these and other NHS agendas all be followed successfully at the same time?

Choice is the mantra of the new NHS in England. Since the beginning of 2006 all patients across the country have theoretically been able to choose where and when they get hospital treatment—a great leap forward in empowerment of patients, if we are to believe ministerial statements on the subject. Hernias in Halifax, gall bladders in Gloucester: the world's your lobster, my son, as Arthur Daley used to remark in Minder.

But it is never long in the NHS before one policy begins to collide with another. No sooner was choice up and running than ministers discovered the joys of localisation. Services offered locally, conveniently, and more cheaply formed the basis of Our Health, Our Care, Our Say, the white paper that also emerged in 2006.

GPs and independent companies are now being encouraged to provide such services in competition with hospital trusts. Primary care trusts are uneasy about this—and with good reason. Rightly or wrongly they still feel a responsibility for the preservation of secondary care; and an uncontrolled “free for all” could seriously disrupt the local NHS economy.

The lack of clear market rules is a major problem. Combined with practice based commissioning, the choice and localisation agendas have created conflicts of interest that are screaming out to be resolved. Services that are based in primary care occupy a favoured position. Under practice based commissioning, GPs both provide and commission these services, abolishing the purchaser-provider split that is the basis of the market—and then are free to refer their patients to them. Primary care services that aim at keeping people out of hospitals are also allowed to undercut the tariff, giving them a competitive advantage. The result is potentially unfair to hospitals and to the private sector providers that the government has encouraged to enter the market.

The aim of practice based commissioning was to counter the tendency of secondary care to soak up all the available resources by giving GPs an interest in keeping patients out of hospital. But it cannot, surely, have been intended, in the words of Simon Stevens in a recent issue of Health Service Journal, to be “an opportunity for GPs to form local cartels capable of channelling taxpayers' cash to their own, for-profit, practices through the supply of substitute secondary care or diagnostic services, entirely immune from normal procurement rules or fair and transparent competition.”

Mr Stevens, of course, has interests of his own. A former health adviser to the prime minister, he now chairs UnitedHealth Europe, which itself is bidding for contracts to supply such services. However, he is not exaggerating. The healthcare think tank the King's Fund made the same point in more moderate language in a recent report, calling for the Department of Health, “as a matter of some urgency,” to provide a clear set of rules for competition in health care.

Take choice, for example. It applies only to treatments “on the tariff,” the list of prices that hospitals are allowed to charge for each procedure. Hospitals are not allowed to charge less than the tariff, so giving a patient the choice between a range of hospitals is cost neutral for a primary care trust. But GPs' services are not on the tariff. They are allowed to charge less. And because they are not on the tariff they are not formally part of choice. Patients can be encouraged to use such services without being offered choice at all—and, because these services are provided by GPs whom they trust, are likely to do so.

True, the national guidance Choice at Referral says that although many patients will be content to choose from local services, “GPs will be expected to tell patients that the new national menu also exists and to discuss clinically appropriate options available.” The General Medical Council says that there is a more general duty to inform patients if GPs have any financial interest in an organisation they plan to refer them to. What happens if they don't? They are hardly going to be named and shamed, I suspect, or struck off or even rapped on the knuckles. How will anybody ever know?

The losers will be the acute trusts, who will find it increasingly hard to compete for patients against GPs with a special interest or GP funded diagnostic centres and the private companies hoping to get a foothold in the market. Few in the NHS would shed many tears for the private sector, but without its involvement the market simply won't fly. The benefits of marketisation will be lost, and another reform will bite the dust without having even dented the tough carapace of the NHS. This may be just what many doctors and primary care trusts hope for, but it is not the government's intention.

Quality is also an issue. GP provided services fall outside the remit of the Healthcare Commission, so nobody will know if they are as good as those delivered by acute trusts. The evidence so far is not especially encouraging.

Research carried out by Martin Roland and colleagues at the National Primary Care Research and Development Centre at Manchester University and commissioned by the health department found that GPs were good at delivering care for chronic conditions but less good at minor surgery, and that GPs with a special interest deliver more accessible care and shorter waiting times than hospital outpatient clinics ( But the cost of services provided by GPs with a special interest is actually higher, and such services running without the support of local consultants may be unsafe. The research concludes that moving secondary services or specialists to primary care settings does not reduce referrals and loses the economies of scale that hospitals provide. How odd it is that the health department didn't issue a press release to alert us to this interesting study.

The choice and localisation agendas have created conflicts of interest that are screaming out to be resolved

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