Dangers of putting GPs in charge outweigh the rewards
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Picture this. It is June 2011. Health secretary Andrew Lansley meets with chancellor George Osborne and the prime minister. The health secretary explains that his decision to give GP commissioners the right to sign off reconfiguration plans means that efficiencies are taking longer to find than hoped. The chancellor, already alerted by officials to the dangers of placing £60bn in the hands of reluctant and uncontrollable GPs, stresses the NHS has already had more than its fair share of public money.
David Cameron, remembering his commitment to dealing with the deficit while not “cutting the NHS”, will demand immediate action before the situation gets out of control.
When the economy is profoundly challenged, the only question that matters is “who controls the money?”
How did it come to this, he may also ask? The answer may well be traced back to the decision to strip primary care trusts of the majority of their commissioning powers.
From April 2012 local managerial influence over the bulk of commissioning is set to be dramatically reduced. Mr Lansley’s radical vision will effectively transform PCTs into regional public health offices, debating forums for local opinion and a useful repository for “residual” services.
All these roles have value - but at a time when the economy is profoundly challenged, the only question that matters is “who controls the money?”
In the NHS, the bulk of the budget is tied up in providing relatively few areas of treatment. If you are able, for example, to use commissioning powers to influence the care of those with chronic obstructive pulmonary disease you hold the key to significant savings.
“Control” of NHS spending will therefore be played out in the tension between the Department of Health’s independent board and around 500 GP consortia.
As a streamlined contracting regime, the new approach seems to fit the spirit of the age. No intervening bureaucracies to slow the radical and rapid change needed. It also aligns neatly with GPs’ new role as reconfiguration gatekeepers.
Why then do so few people - many actually involved in shaping and delivering the policy - believe that it will work? Readers are likely to have their own answers to that question. HSJ believes two stand out. The first is that of accountability.
PCTs’ last act as commissioning agents will be to ready an army of GP consortia, the majority of which do not exist yet. They will be coming to commissioning with little or no experience and will need some persuading to shoulder responsibility.
At a national level, the DH will be attempting to renegotiate the GP contract with the British Medical Association, while working out where the statutory duty to ensure high quality health services will lie.
Even assuming PCTs are successful in creating the critical mass of consortia, GPs could be taking up spending responsibilities at a time when the “locally representative” PCT boards come into place.
Elected representatives tend to assume they have the right to exercise power. GPs will see this potential clash coming and attempt to avoid anything that might tarnish their reputation and position as the patient’s champion.
The second major question about the wisdom of placing so much power in the hands of GPs is how quickly change can be delivered.
Even with the most ingenious implementation plan and an enthusiastic response from GPs, it will be half a decade before this new system is delivering real results across the system. Does anything you have heard from the new government suggest that it thinks the UK can wait this long to re-engineer the cost base of its public services?
The only trouble is that, having placed so much faith in GPs and with the best SHA and PCT managerial staff already lining up top jobs with GP consortia, the government may soon find the ability to control the direction of the NHS has slipped through its fingers.
Our hypothetical meeting between the PM, chancellor and health secretary may end in an uneasy silence and accusatory looks.
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Readers' comments (13)
Anonymous | 10-Jun-2010 12:54 pm
Most of the policy decisions so far have been good. Cutting waste (PCTs/SHAs etc). Focusing on the independent NHS Board (hopefully truly independent and full of clinical managers and experts not political managers). But the assumption that GPs are best placed to drive the NHS locally is flawed. Most don't want to. Those that do are often full of self interest. The handful that are interested for altruistic reasons are too few. If PCTs and SHAs morph into GP consortia we're no better off.
Let's hope Lansley moves to engage the right GPs into a national model for commissioning and consortia are left to deliver the national health service model not muck it up with local variation and postcode healthcare.
Having said all that. How is it that Lansley keeps making these announcements. Where is the CEO of the NHS? What's his job now?
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Anonymous | 10-Jun-2010 6:06 pm
Dangers of doing nothing is even higher. Unfortunately the system is broke and needs a big shake up. The dangers of PCTs and SHAs being left to run the NHS for another 5 years is just not acceptable. The latter will give us more of the same – more money wasted, more care at lower quality, more bureaucracy, and less innovation. PCTs and SHAs have failed according to SoS, and Health Select Committee, and they need to go.
Ideally, the new GP commissioning structures need to start from April 2011. Leaving it till April 2012 will result in more of the same for another year.
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Anonymous | 10-Jun-2010 7:07 pm
Something a lot of people seem to be missing is PCTs will still exist to commission the stuff GPs don't want to do, and maternity services. One of the big whinges from colleagues in the acute sector has always been there are too many commissioners. We went from 303 PCTs to 152 at the last reorganisation. Now we are going to about 500 consortia, 152 PCTs, oh, and don't forget the 10 SCGs.... Let's be kind and say PCTs will merge to half of their existing number - the future is set for around 600 commissioners moving forward!
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Anonymous | 10-Jun-2010 7:11 pm
I bet the share prices for all those private 'commisioning' consultancies or support agencies just went through the roof.
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Anonymous | 11-Jun-2010 9:58 am
We need less administrators not more. How much money will be wasted 'managing' all these commissioners? We need fewer, bigger organisations with minimum management structure and maximum workers.
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Anonymous | 11-Jun-2010 4:04 pm
Fascinating scenario - both believable and likely. At the moment the policy rhetoric is veering increasingly out of control; it’s like a teenager has been given access to every single computer game on the planet and can’t wait to push whichever newest and shiniest button comes to hand, without any idea of what’s actually likely to happen.
Let’s get this straight. What appears to be being proposed is that – without any robust evidence base whatsoever - £60 bn is handed over to groups which haven’t been defined, (let alone established), run by staff who might not want the job they’re being given, and accountable through a mechanism that might or might not be there, performance managed against something that’s not targets but will be standards which haven’t been outlined yet. And this has to deliver £20 bn plus of efficiencies/cuts/savings/reshaping (choose whichever suits your mood or manner), involving potentially massively difficult decisions, many of which have already been pushed back further and made more difficult by recent policy requirements. With Treasury – understandably – panting at their heels. And how do all these groups do the macro stuff that’s needed in many areas ?
Moreover, staff that could support this work could be flung to the four winds of chance, and systems of governance cast asunder like so many broken toys and replaced by promises of well…..further guidance in July.
Heavens to Murgatroyd, GPs are good, but they’re only human. Radical reform ? Great. New ideas ? Excellent. Clinician and patient voice central ? Can’t fault it. But as the baby goes squealing out with the abandoned bathwater, and an abandoned bath and baby-shaped void begs a mass of sensible detailed questions about how it’s all intended to work, can’t we all be excused for feeling a little bit concerned ?
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Anonymous | 13-Jun-2010 10:41 pm
Given that GPs have to be paid to do anything extra (e.g. the fee for swine flu vaccination), I'm guessing that they won't take on any new responsibilities without more lucre.
Most GPs I have spoken to have only the vaguest idea about what the NHS reforms are all about. Why should they, when they don't even work for the NHS?
GPs are very good at advocating for their patients, but that isn't commissioning.
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Anonymous | 14-Jun-2010 10:09 am
The only way this would work is to contract the new GP companies with fixed budgets from which they are legally bound to provide services. Any overrun will be at the cost of the GP and not as now either DH or SHA. If it is contracted this way then you can imagine that a GP will want to protect budgets. If it is a 'here is a bunch of money and Oh if you over spend we will pick up he bill' scenario then as you predict that conversation will be interesting if he is still in office.
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Anonymous | 14-Jun-2010 11:27 am
What seems not to have been acknowledged is the conflict of interest. How can you give GPs MORE accountability when they do not see them selves as financially accountable in the first place and are currently focussed mainly on those areas of health care provision where they can suppliment their already generous income by designing locally enhanced services and them paying themselves more . Currently they tend to steer clear of those less glamourous areas where they cannot make an additional profit and with then "0n costs" that they are demanding they often work out more expensive that the acute tariff. To give them more power and the ability to make more money would be a disaster....
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Bob Neilans | 15-Jun-2010 7:46 am
My neighbour recently went into hospital for an operation on his hand - he can exercise but not use the fingers for dressing, cooking etc - the operation was performed in a hospital 60 miles away from his home. You would not believe the trouble and downright obstruction in organising transport, social services, physio treatment etc - Any system that improves on the current which is very good at delivering the intervention but useless at after care has got my vote! So we may ruminate on whether GPs or PCTs should commission - I'd just like a system that works!
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Calum Paton | 15-Jun-2010 1:34 pm
See my article in the forthcoming July issue of Public Servant, 'The Coalition and Health Policy - Too Liberal a Dose of Conservatism.'
What is amazing is that Lansley was Shadow Health Secretary from 2004 (when he was welcome on the solitary ground that he was not Liam Fox, his predecessor!). He had gone native (in the good sense...ie not a naive interloper). So why, oh why, is he seeking to combine the worst of GP fund-holding (GPFH) with the worst of Shifting the Balance of Power (StBoP) (remember that mess....which had to be reversed in 2006?) and the worst of Practice Based Commissioning.
The worst of three worlds.
The comment above is quite right: most GPs don't want to do this.
But it always appeals to pols preaching 'localism and devolution'...as the GP sounds like the next best thing to the patient. Seems LibDem localism and Tory devolution have rubbed up well together.
But more: when the worst excesses of StBoP were removed in 2005/6, they came back instantly via the backdoor of PBC....and now the new consortia will /would be an even less efficient version of that.
Your scenario is quite right, in the main....except for your suggestion that it would take half a decade to get the benefits. We've had 'purchasing/commissioning' since 1991 and have not had the 'benefits' in two decades.
Add to that that we are just reacjhing 1993 in merginf merntal health trusts and communoity services (which were the 'commnunity trusts' of the original internal market; later divested of their community services which went to PCTs in 2001/2; now back where they started via the half-way house of 'provider arms' of PCTs (just like the directly managed units of the early 1990s...
Does Lansley know this? Does he care? What does he tell Cameron and Osborne about the costs of the policy per se and also the costs of the perpetual re-disorganisations?
I hope that the NHS CE and his team are talking frankly to the SoS, and not doing the tempting 'kissing up.' Isn't that the point of having an NHS CE separate from the PS...to lead the service, and speak truth to power on behalf of the service, and not just be highly-paid letter writers from the centre to the troops?
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Anonymous | 15-Jun-2010 1:56 pm
There seems to be a preconception that most waste (Anonymous 12:54 et al) is in SHAs and PCTs - and yet some research just completed shows that in one local acute, 22 per cent of admissions are inappropriate and lead to even further costs through adverse events like falls and HCAIs. Anyone think GPs will do anything to reduce this? Who do you think is making the inappropriate referrals in the first place! Now is the time to be driving forward with savings programmes identified. Lansley is intent on throwing out the baby with the bathwater, then scrapping the bath, remodelling the bathroom and selling the whole house.
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Anonymous | 18-Jun-2010 11:38 pm
When GPs send patients into hospital, the hospital has every right not to admit the patient. So, when you talk about inappropriate referrals, if the hospital doctors dont believe the patient should be admitted then they should be sending the patient back home and not admitting them. So, what precisely do you mean as inappropriate referrals. If a patient is admitted then surely there was something wrong with them in the first place.
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