On ‘tender’ hooks

The Competition Authority’s report into the GMS suggests an unstoppable force towards corporatisation, writes Dara Gantly

It would seem even the Competition Authority (CA) has its limit. Cast your mind back to this time last year – well, July 16 to be precise – and the publication of the McCarthy Report. As doom and gloom went, An Bord Snip Nua was pretty heavy going: staff reductions of 17,300; the axing of entire Government departments; and rationalisation across the board, which would save €5.3 billion in a full year. Oh yes, it also recommended competitive tendering for GMS contracts.
For the past year, GPs have been on tenterhooks, or perhaps that should be ‘tender’ hooks, over the proposal. Many were waiting for the last of three reports into the GMS carried out by the CA to point the way forward. Now that this report has been published, many may seem surprised, if not completely relieved, by the stand the Authority has taken.
In Appendix A of the report, ‘Increasing Competition within the General Medical Services (GMS) System’, the Authority stated that in the absence of detail from either the HSE or McCarthy on how such a system might operate, it was difficult to assess what the effect of competitive tendering would be and, in particular, how it would impact on patients.
It believed the idea for competitive tendering appeared to come from the UK model of Primary Care Trusts. However, there were important differences in the way GP services were provided in the two countries – none more so than the lack of universal access to free GP services in Ireland.
The CA indicated that the level of planning and administrative oversight required under a competitive tendering system should not be underestimated. “It may prove to be far higher than the resources currently applied by the HSE to administer the GMS.” It also noted that such a move would require major investment in the upgrading of information and management systems within the HSE.
As previously reported in IMT, the main arguments put forward by the IMO against the introduction of competitive tendering were that it would result in the corporatisation of primary care and the dismantling of community practice – a viewpoint seemingly shared by the Joint Oireachtas Committee on Health, which earlier this year (February) came out in support of the development of primary care centres by the professionals who would be directly involved in them.
The IMO sees corporatisation as a ‘bad thing’, and believes that allowing large medical corporations to become involved in the delivery of GP services will “pit GPs against GPs and GPs against medical corporations in bidding wars for GMS contracts”, and will “allow private companies with no experience in healthcare to operate services under the GMS… GPs will become mere employees”.
There will, it argues, be “obvious tensions” between “the physicians’ role to act in the best interest of the patient and that of a commercial body whose prime interest is to make profit for their shareholders”.
In response, the Competition Authority believes that these arguments against the principle of corporatisation are “not persuasive”. “Corporatisation is already happening,” it stated in its latest report. “The structure of general practice in Ireland has changed considerably in recent years; one of the changes has been a trend towards increased corporatisation.”
The Authority believed this was evident, for example, in the development of GP out-of-hours co-ops and in the growth of neighbourhood medical care centres, which incorporate a range of primary care services.
The CA states that patients have no inherent interest in who owns or operates their GP surgery, except in so far as it impacts on the quality of care they receive. It also believes that looking after patients’ interests and making a profit are “not necessarily mutually exclusive”.
It also believes the debate about competitive tendering should not be reduced to a discussion of the pros and cons of primary care corporatisation. “This trend … is happening already and is likely to continue, regardless of whether there is any change in the manner in which GPs are contracted by the State under the GMS.”
The IMO suggestion that a tendering system would result in poorer access to GP services in local areas or allow companies to ‘cherry-pick’ the most profitable aspects of patient care was, said the Authority, not a criticism of tendering, but a reflection of a poorly-designed system.
“It would be the responsibility of the commissioning body (the HSE) to design a system which ensured adequate service provision in all areas of the country, and which specified clearly the care to be provided to patients by contracted GPs. If the contract is properly designed and enforced, it should not be possible for contractors to ignore parts of the country or select only the most lucrative aspects of patient care.”
The CA believes concerns about the continuity of care under a tendering system merit debate. “There is a potential conflict between patients’ desire to have a long-term, continuous relationship with their GP and the likelihood of changes of GP, under a tendering system.
“The essence of any tendering system is that tenders will be for a limited duration, and there will be penalties for non-performance. If the system is to have any practical effect, there must be winners and losers. The immediate losers… would be those GPs who failed in their bid to acquire or retain a contract. The indirect losers would be the patients of those GPs, who must switch to another doctor.”
The argument that these patients will be offered the services of a ‘better’ GP may not be convincing to patients who have a long-term relationship with their family doctor, the CA acknowledged. It accepted that an important ‘attraction’ of the current GMS system, in theory at least, was that it placed the patient (not the HSE) at the centre of performance management. “Under the ‘choice of doctor’ scheme, patients become the ultimate arbiter of performance,” the report stated.
The introduction of competitive tendering could raise a number of patient concerns. GPs could lose a contract to treat public patients based on concerns about the performance of the wider corporate body, rather than due to performance deficiencies on their own part.
Most patients value the stability of a long-term GP relationship. “They are likely to oppose a forced change of GP or the prospect of repeated changes of GPs over their lifetime,” the Authority added. These problems, it said, could potentially be avoided if failure to retain a contract under a tendering system resulted only in a change of the administrative/managerial function, leaving the actual GPs unchanged.
The Authority concluded that a clear picture needed to be developed of what such a tendering system would entail, what it would mean for the provision of GP services, and what the impact on patients was likely to be. While it felt such a system could “remove the IMO from its position as power-broker for the GMS”, it stressed that if the move was intended primarily as a way of controlling costs, there may be other options available to do this.
“The case for moving to a wide-scale system of competitive tendering is not clear,” it concluded.
A thoughtful, fair and balanced report from the Competition Authority? Surely not.