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LET PEOPLE CHOOSE THEIR GP PRACTICE
By Alison Payne, Research Director, Reform Scotland
General Practitioners are often a patient's first and only contact with the NHS in Scotland. However, unlike hospitals which are owned and operated by the public sector, the vast majority of GP practices are actually private sector contractors to the NHS.
Although surgeries can be run directly by the NHS boards in Scotland, most operate under either locally or nationally negotiated contracts. According to ISD Scotland currently only 6 per cent, or 59 out of 943 GP practices, are classed as a "2C practice" – a practice which is run by an NHS board. The other 94 per cent are private sector contractors.
Reform Scotland has no problem with private sector contractors, in this case GP partners, being given public money to deliver public services, and, if structured properly, a diverse range of providers can help raise standards across the board. However, that doesn't mean there isn't room for improvement.
For example, according to a Freedom of Information response Reform Scotland received from the Scottish Government, there are currently no obligations placed on GP practices to publish or provide their health board with a copy of their annual accounts, that is despite the huge amount of public money that is spent in this area. There should be transparency and accountability when it comes to the use of taxpayers' money, which is why Reform Scotland believes that any organisation that receives taxpayers' money should have to publish annual accounts which are available to the public.
There are also restrictions on who can be a GP partner. The Tobacco & Primary Medical Services (Scotland) Act 2009 requires all contracting partners to regularly perform or engage in the day-to-day provision of primary medical services. As a result, commercial companies are prevented from entering into a contract with a health board. However, just because there are restrictions on who can be a partner in a GP practice, does not make that practice less private, it is still a private sector business, contracting with the state to deliver a public service. When the legislation was debated in the Scottish Parliament, Labour MSP Rhoda Grant commented:
"I do not see why one private is good and the other private is bad. I do not understand why one private contractor's motivation is different from another's."
The current situation where some private enterprises can run GP practices while others can't, is illogical. Either you believe that the private sector should not be providing GP care, in which case all GPs should become salaried GPs and be employed by the NHS, or you believe that the private sector can provide GP care, as it currently does. Trying to ban certain types of private sector providers, but allowing others based on their perceived motivation is inconsistent, which is why Reform Scotland believes that the ban on commercial companies running GP practices should be lifted.
There can be a great deal of variation in how GP practices operate. Reform Scotland has previously examined the access arrangements across Scottish surgeries. We found that while some practices allow you to book an appointment a couple of weeks in advance, others only allow you to book an appointment for that day. Some offer extensive extended hours cover, while others offer none at all. Some allow patients to order repeat prescriptions or book non-urgent appointments online, while many others do not. We also found there was no correlation between the size or location of a GP practice and the access arrangements in place.
Surveys such as the Scottish Government's Health and Care Experience Survey highlight patient frustrations. In the 2009/10 survey 81% of respondents found the overall arrangements to get to see their GP 'excellent' or 'good'. By the 2017/18 survey this had fallen to 67%. The survey also noted that only 68% of people said they could book an appointment three or more days in advance, down from 77% in 2013/14, and was "significantly below" the Local Delivery Plan Standard.
Such variability in provision would surely be unacceptable within publicly-owned and operated services, but this lottery is actually a state sponsored monopoly operated by the private sector because patients have little, if any choice in the practice they are registered with.
Whilst some people will live in areas covered by a number of practices, others will be covered by only one. Yet, even finding out what your existing choice is, is not straightforward. To find a GP in Scotland there is a "find local services" tool on the NHS inform website. However, it simply presents you with a list of GP surgery addresses and their distance from that location. It does not tell you whether they cover your area, nor does it give out any useful information. In contrast, the NHS Choices search which covers England informs people whether the practice is accepting new patients and whether it offers online booking and online repeat prescriptions.
Reform Scotland believes that giving individuals greater choice over their GP surgery would mean that people were able to easily walk away from GP surgeries they felt did not provide services that suited them. We don't envisage that such a policy would lead to a mass exodus of patients from GP surgeries, but the potential that they could would give them much greater influence over the way services operated in their area. It is also worth remembering that when the NHS was set up in 1948, information leaflets advised that the first thing people had to do was "choose your own doctor". Therefore, what Reform Scotland is proposing is nothing particularly radical or even that new, but an extension of something which patients were advised they could do when the NHS was set up over sixty years ago.
Reform Scotland's briefing, GPs Offline, can be read here and the report Examining Access: Survey of GP Practices in Scotland can be read here.
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