All Change – The Role of the Independent Sector in Primary Care Provision

by Geoff Benn, Group Marketing Director, Care UK.

There’s not much common ground between Bob Dylan and the healthcare sector, but there is one thing we can agree on – the times, they are a’changing.

Primary care has long been a bastion of the NHS, and the development of a role for independent providers within it is key to the Government’s drive towards plurality.

Behind the drive are a number of factors and influences which are shaping where we are today, and where we will be in the future.

The first is the directive to move some hospital services to the primary care arena. This is about providing what have traditionally been secondary care services, such as diagnostics and outpatient consultations, nearer to home and out of the acute hospital environment. This is designed to free up resources within acute hospitals and develop a trend for more community-based services.

The second is to improve the range and accessibility of primary care in areas where the NHS has found it hard to maintain quality provision. This is particularly true of the areas of the UK that are under-doctored or where secondary care provision is under pressure from primary care demands.

The big catalyst for change was the introduction of the APMS (Alternative Provision of Medical Services) GP contract in April 2004. This changed the old way of doing things, which provided for either a GMS (General Medical Services) or PMS (Personal Medical Services) contract that put doctors in charge of running their practices.

The APMS contract allows the independent sector to run GP practices and employ salaried GPs. This means that the ‘business’ of running a GP practice is put in the hands of experienced management teams, leaving the doctors and other healthcare professionals to get on with what they do best – providing direct patient care.

Care UK was fortunate enough to be granted the contract to run the first such GP practice in the UK, at Barking and Dagenham. The contract includes a GP practice and walk-in centre.

Barking and Dagenham was a classic example of why there is a need for the independent sector to play a role in the provision of primary care. The local PCT could not recruit GPs to the area and research showed that around 7,000 residents were unlikely to be able to register with a GP.

We have worked hard to develop a multidisciplinary approach to the contract, and the combined GP practice and walk-in centre mean that we have been able to make the most of efficiencies of scale.

The new GP practice and walk-in centre in Dagenham will be able to treat 7,000 patients in the GP practice and up to 100 patients each day in the walk-in centre.

The new centre will employ three GPs and seven nurse practitioners, along with associated support staff.

It is so far working as predicted, providing the same range of services expected from a GP practice with an efficiency of management behind it.

The involvement of the independent sector in the provision of primary care has, however, not come about without some unique challenges.

The status quo, issues around the integration of independent sector run centres in to the healthcare system, ‘newness’, fear of the unknown and ‘urban myths’ (such as the cherry picking accusation) have all contributed to some negative comments on the programme.

Where we have won contracts, we have worked hard to communicate to the medical community and local patients. Our approach to our contracts has a strong customer focus – both in terms of patients and our PCT partners. The independent sector is good at looking after its patients, which is why we react to patients’ needs and build our service around the patient.

With regard to the accusation of cherry picking – nothing could be further from the truth. We have to factor-in providing the full range of services in order for our business to grow. We cannot truly support the objectives of the Government programme if we pick and choose the cases we treat.

So, what are the opportunities moving forward?

Key to the future development of the programme are LIFT schemes. These have traditionally been about property, and improving the property stock in primary care. We are already at phase four of the LIFT programme, and so far there has been little focus on the development of service provision.

We see real opportunities for the use of LIFT to bring diagnostics into general practice – for on site diagnostic imaging, endoscopy, arthroscopy et al, with provision for visiting mobile MRI and CT units. There is no reason why such services cannot be delivered in the general practice environment, particularly when GPwSIs (General Practitioners with Special Interests) and extended-role nurses are factored into the equation. This would certainly contribute to the hospital admission and emergency avoidance strategy. We also see great opportunities following the publication of the white paper  ‘Our health, our care, our say’ and the resurgence of community hospitals.

And who knows where this line of action could go with regard to surgery? Could we see the development of small operating theatres in general practice, with visiting consultant surgeons carrying out intermediary surgery such as hernia repair and vasectomies? Surely the end result would marry with Government objectives, which are to free up the resources of acute hospital and develop the provision of primary care in the community.

Another area for development is linkage form primary care into social care and the voluntary sector. Driving this are efficiencies of care provision, as well as practice based commissioning and payment by results. There are gaps to be filled, and Care UK is already taking steps to fill these – for example, we are currently talking to the voluntary sector regarding sexual health.

And finally, the greatest contributor to the future development of the role of the independent sector within primary care provision would be a review of the role of lists in how services are set up.

At present, the extent of the services a practice is able to deliver is based on its patient lists - on average 1871 patients per GP. Using the list head count is the basis of the capitation charge calculated by PCTs, but given the changing role of primary care and the demands to be placed upon it, is this the most appropriate way to take the programme forward?

You can contact Geoff by email at