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The doctor will see you now

This article by Alison Payne appeared in Scottish Policy Now.

The NHS in Scotland and the many men and women who work in it day-in-and-day-out perform admirably and are deserving of the praise they often receive.

However, that doesn’t mean those services could not be organised in a different way that better suited the public. Surveys such as the Scottish Government’s Health and Care Experience Survey tend to suggest that while the public praise the care they receive, there can be frustrations with the difficulty in accessing that care to begin with. The latest report from Reform Scotland, ‘Examining Access: Survey of GP practices in Scotland’, looked at the access arrangements for every GP practice in Scotland, considering whether they had a website; allowed repeat prescriptions to be requested online or via email; whether they advertised extended hours online; and, whether they allowed routine appointments to be booked online.

The results indicated that 67% of GP practices had a website, 51% allowed online/email repeat prescription requests and only 10% allowed appointments to be booked online. This was despite the fact that four years ago the Scottish Government developed a toolkit in conjunction with the Royal College of General Practitioners which highlighted the use of the internet to improve access arrangements, including aspects such as ordering repeat prescriptions online/via email or booking appointments online.

In addition to the main areas we examined, we also made some additional observations. For example, in some GP practices you could only get appointments for that day, whereas in others you could book appointments up to 6 weeks in advance. Some GP practices allowed you to request repeat prescriptions with a fax but not a computer.

 There were practices of less than 1,000 which offered extended hours, online repeat prescriptions and bookable appointments online.
What we also found was that there was no correlation between the size or location of a GP practice and whether it offered all the access arrangements we examined. There were practices of less than 1,000 which offered extended hours, online repeat prescriptions and bookable appointments online. If those practices could offer these services, why couldn’t larger ones?

Such variability would surely be unacceptable within publicly-owned and operated services, but this lottery is actually a state sponsored monopoly operated by the private sector.

Reform Scotland does not object to the principle of private sector contractors providing services for the public sector. Such arrangements can increase diversity, which there needs to be more of in all public services. However, for this diversity to work effectively and to help raise standards across the board, people have to be able to choose between providers.

In contrast for example, when it comes to eye tests, which are performed by opticians working in the private sector, but are paid for by the NHS in Scotland, individuals can choose from a wide range of companies to provide the tests from small practices owned and operated by opticians, to big national companies. However, with regard to their GP practice, people have little, if any choice.

Yet, despite the vast majority of GP practices being private businesses, according to a Freedom of Information response we received from the Scottish Government, GP practices are under no obligation in law to provide a health board, or any other organisation, with details of how they spend public money.
 The debate has perhaps been played down because of the misunderstanding of the status of GP practices. The very fact that within the referendum campaign there were references to the NHS in Scotland not using the private sector for the delivery of care highlights this. We do use the private sector because the majority of GP practices are private contractors.

Although GP practices can be run directly by the NHS boards in Scotland, the vast majority are private sector businesses operating under either locally or nationally negotiated contracts. According to ISD Scotland’s list of GP practices as at 1 April 2014, only 4 per cent, or 42 out of 994 GP practices were classed as a “2C practice” – a practice which is run by an NHS board. The other 96 per cent were private sector contractors.

Almost all funding for these GP practices is practice-based. Expenses such as rent, wages and utility bills are taken out of this funding pot and the amount remaining, after the cost of providing clinical services has been taken out, makes up the pay available to the GP partners. Of course, not all GPs are GP partners; some will be employed by a practice, where their employer is the private sector business, not the NHS; only the GPs employed by the four per cent of practices run by NHS boards are NHS employees.

Yet, despite the vast majority of GP practices being private businesses, according to a Freedom of Information response we received from the Scottish Government, GP practices are under no obligation in law to provide a health board, or any other organisation, with details of how they spend public money.

We are not in any way accusing GP partners of misusing public money. However, there should be transparency and accountability when it comes to the use of taxpayers’ money. Therefore, Reform Scotland believes that any organisation that receives taxpayers’ money should have to publish annual accounts which are available to the public.

Reform Scotland believes that giving individuals greater choice over their GP practice would mean that people were able to easily walk away from GP practices 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 practices, but the potential that they could would help drive up standards. 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”. So what we are 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.

This article appeared in Scottish Policy Now issue 10, September 2014