Competition is not the way to improve general practice

I have lived and worked as a GP in densely populated urban areas for the last 12 years and so I read with interest and dismay, Neil Bacon’s enthusiasm for the findings of the Competition and Cooperation Panel’s so-called: Empirical analysis of the effects of GP competition.

This showed that GPs with neighbouring practices less than 500 metres away made fewer referrals for certain conditions and had patients who were 0.1 per cent more satisfied than patients from practices without such close neighbours.

On the basis of this Bacon concludes, 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.’

From a patient’s perspective, a doctor who they have gotten to trust and that knows them is more valuable than some abstract notion of ‘quality’

In my experience neither the GPs I know, nor the patients I see, behave in the way that the authors of the paper, or Bacon, assume.

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 population, suggests that for the majority of GPs with a greater proportion of older patients this is typical of even more of their work.

From a patient’s perspective, a doctor who they have gotten to trust and that knows them is more valuable than some abstract notion of ‘quality’.

Competition and choice risk increasing inequalities because GPs seeking to maximise their income may design services to satisfy those patients most likely to exercise choice by changing practice – the young and healthy rather than the housebound or seriously ill who need most care.

Fortunately however, 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, is resulting in renewed enthusiasm for these activities. This will, and ought to, drive quality improvement in general practice.

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 be share decisions about their medical care.

It is both futile, and inappropriate, to make it the servant of a medical market place.

Dr Jonathon Tomlinson is a full time GP in East London. Follow him on Twitter: @mellojonny. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.