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Clare Gerada ups the stakes in her fight to ‘save’ the NHS

The unlikeliest and, perhaps, most powerful alliance affecting the delivery of the NHS reforms is between Royal College of GPs chair Dr Clare Gerada and what some might term the “old guard” of NHS managers who have wielded the greatest influence over the last decade.

One management leading light told HSJ that Dr Gerada is convinced she is engaged in a battle to “save the NHS” – something confirmed by her comments in our interview about how the reforms will lead to an insurance-funded system. Few of the old guard agree – finding her analysis naive and simplistic – but they warm to her unabashed love for the service and her ability to chuck spanners into a reform process they have significant doubts about.

Dr Gerada for her part places an enormous amount of faith in NHS chief executive Sir David Nicholson. When HSJ asked how Sir David and senior NHS colleagues were reacting to her opposition, she replied: “I have a lot of people ringing me up in confidence – including very senior people in high places who are anxious about the Health Bill but can’t say it in public because they are frightened for their jobs.”

Dr Gerada is proving a highly effective politician and will seek to maximise any impression that reform is being resisted in “high places”, as well as on the ground. However, HSJ has spoken to many of those same people and knows there are concerns aplenty.

Little wonder, therefore, that old rivals the NHS Alliance and the National Association of Primary Care have formed a coalition to try and maintain what momentum remains behind GP commissioning and to resist what they see as the danger of smothering centralisation.

It will be interesting to see how they respond to Dr Gerada’s latest upping of the stakes by raising the spectre of GPs falling foul of the General Medical Council should they become complicit in commissioning decisions which “conflict” with their duty to patient care.

The introduction of clinical commissioning creates no new fundamental principle or risk that is not already covered by GMC guidance. However, if the government is successful in rolling out the commissioning reforms it is a risk that will be borne by many more medics on a much more regular basis.

The GMC will no doubt explore the implications of this during the imminent review of its guidance. However, the steps needed to systematically protect GP commissioners from the risk could yet prove another stumbling block for the implementation of the reforms.

But what of Dr Gerada’s central point that GPs should not become involved in “rationing”? The answer to that question, of course, depends on what you mean by rationing. Responding to Dr Gerada’s interview on hsj.co.uk, many readers commented that GPs already “rationed” care through referral decisions and that, if the NHS was to live within its restricted means, medics would have to take greater responsibility for the use of NHS resources.

Her challenge exposes the fault line that runs through the NHS – and has since its birth. Public funding has allowed clinicians to be removed from most of the financial implications of their decisions. Indeed, many would see it as a strength of our system. Dr Gerada believes that more money should be spent on healthcare, calling for a repeat of the Wanless review which provided the intellectual ballast for the 2002 NHS budget bonanza.

However, given that another step change in NHS funding seems near impossible in the foreseeable future, the “rationing” issue is not going to disappear. The medical profession is still going to have to decide whether it leaves those decisions to others or shoulders the professional and reputational risks of getting its hands dirty.

Readers' comments (9)

  • Clive Peedell

    Clare Gerada is right to be worried about the drive towards a mixed funding system.
    The reforms will clearly lead to this situation.
    The bill aims to maximise the number of purchasers and providers in the system to generate market competition (Lansley's words, not mine). This is clearly a major problem for a single payer system, especially in the context of the QIPP agenda.
    Thus, the NHS needs to cut services and get extra capital.

    Services will be rationed by the CCGs and waiting lists will go up. NHS 'core services' will diminish over time. This is why Lansley needs to absolve his duty to provide a comprehensive service and place it in the hands of the NHSCB and CCGs.
    This all drives the healthcare insurance market. There is clear evidence that when waiting lists go up and services decline, there is increasing uptake of private medical insurance. The other insurance driver is patient held budgets, which will result in a top up insurance market. In the next parliament, patient charges will also come in - another reason to take out insurance.
    The abolition on the Private Patient income cap for FTs is crucial for FTs to survive in a new market with many CCGs in deep financial trouble. They will need to ramp up their PP operations and will need to advertise these services.

    We are clearly heading towards a mixed funding system. The NHS ie the state, will continue to fund core services, but these will decline over time because of the huge costs of creative destruction of the market. The delivery of NHS care will increasingly be delivered by private sector organisations. FTs will become social enterprises (denationalisation by mutualisation) and all new employees are likely to have "private" contracts, rather than NHS T+Cs.

    Meanwhile the pro market think-tanks funded by the private healthcare coroporations and financial institutions keep blowing the reform trumpet.

    Tragic, but true.

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  • A GP making a referral should be thinking about what is best for their patient regardless of the cost. This will change when the cost becomes an issue (I'm not suggesting a GP would make a decision to not refer for personal gain, but they may have to if the CCG is struggling financially and they are under pressure to reduce elective procedures across the board).

    Restricting care in this way will inevitably lead to an increase in waiting times and a growing frustration among patients. At this point, anyone who can pay for healthcare insurance will start looking elsewhere – and you can bet that the big healthcare insurance companies are gearing up for some extremely good loss leading “introductory offers” to get us hooked.

    In time (around a decade I’d guess – as this would tie in nicely with the ageing population bubble) a tipping point will be reached whereby the vast majority of the UK population will have private healthcare insurance.

    What will be left as “free” will have been successively eroded in the interim until all that remains is a USA “Medicaid” clone offering only basic emergency cover to those who can’t afford to pay.

    With the state system destroyed, insurers can start to up their premiums safe knowledge that we have no alternative and voila 20% of UK GDP will end up being spent on healthcare – double what is spent now with only a privileged few getting better care than we all have access to at present…

    When I discuss this with friends, even staunch conservatives, they are truly shocked at this (very real) prospect and how well this eventuality has been hidden from the public in all of the reform bluster.

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  • Clive Peedell

    http://www.guardian.co.uk/business/2011/sep/13/private-healthcare-boosted-by-nhs-rationing?CMP=twt_gu

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  • Sadly I think both contributors above have an excellent measure of what these so-called reforms are all about - perhaps a touch pessimistic. The public do yet know what is going on and when they realise it they will be angry and ready to be mobilised. The media will go for the government when the inevitable horror stories emerge. Labour, however, needs to enter the confessional for introducing Foundation Trusts which are the basis for independent producers and the means by which an internal market may so easily become an external market. Once in receipt of 'absolution' the Party can vigorously campaign to re-nationalise the health service.

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  • Martin Rathfelder

    Rationing is inevitable. The great strength of the NHS is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged. Lansley's reforms will lead to a system where the poor get basic treatment and the rich are over investigated and over-treated.

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  • I worry that in the future, when doctors get together, they will stop talking about patients and difficult cases and start talking about the business of medicine. This will be a huge and unquantified loss to the NHS and patient care.

    I think it's important to distinguish between health planning for a community as a whole and "rationing" care for an individual patients.

    Doctors should absolutely be involved in health planning. Where are the unmet needs, and what services, facilities, or providers do we need to fill them? That's a good thing to ask physicians to think about from time to time. Ditto for quality.

    But that doesn't mean we should turn doctors into billers and negotiators and purchasers of every paper clip and appendectomy, which of course they can't do and have to hire an insurance corporation to run for them.

    I think that we all need to be mindful as to what the reforms will be doing for the dr-pt relationship, both in primary and specialist care. Patients have to trust that we are doing what we are doing in thier best interests.

    Clare

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  • I think that when the President of the Royal College of Gps is " upping the stakes" we should listen. It seems that GPs are not wholeheartedly behind these changes, despite what Lansley might say. There are genuine worries, that care will be rationed and incresingly fragmented. I am aslo worrried by the header that says that there is to be a meeting entitled the " implementation of the health and social care bill. It has not yet been ratified.

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  • I think Patrick Newman makes a very valid point about the true architects of all this being Labour. During their time in power they have given us FT's and Transforming Community Services (Where Social Enterprise came from) so I guess they find themselves in the unenviable position of shouting down something which they effectively concieved. Never easy for politicians, especially given how much good they did also.

    But the concerns of GP's are very real and should be listened to. More importantly the future of our cherished health system - the NHS - is too important to trivialise and experiment with to satisfy huge ego's and the fleeting aspirations of here today, nowhere tomorrow politicians.

    Nobody is arguing that the NHS is perfect and doesn't need to change. But what are we trying to change it to? Is everybody crystal clear what that change means? Are there unintended consequences which will actually do harm?

    And should it not be premised upon change to improve services for patients (don't forget we are all patients) not just to save money?

    Jury's still out for me.

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  • My organisation initated a petition for GP Commissioners to sign if they opposed the health bill and were involved in commissioning only to defend their patients and local services. In August alone we had over 500 GP commissioners sign up.

    This bill is unfit for purpose, unhelpful to service design and delivery and should be withdrawn. Founders of the NHS Alliance like me are disgusted with the Alliance's pathetic enthusiasm and poor understanding of the Bill

    Ron Singer, Medical Practitioners' Union-Unite

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