In seeking to diminish the role of the state, the government has established a policy that attacks NHS bosses as the cause of most problems and abolishes state run primary care trusts and strategic health authorities. Instead, it proposes GP led consortia to do commissioning.
There are two reasons, it argues, why these consortia will be better than existing state organisations. First, they will be led by GPs, who understand the relationship between commissioning care and individual patients better than NHS managers. They also have 60 years’ experience of working in small business organisations. They think, act and feel like businesses people. Unlike state organisations, they understand the economics of investing in something today to make money tomorrow, because that is how businesses work.
GPs, after 60 years of not working for the state, are unlikely to willingly work for it now
The government believes the combination of these incentives will make such a transformation in NHS commissioning to be worth the upheaval of the next three years. But the white paper undermines that. It says the GP consortia that will be running most of the commissioning for the NHS will have to become statutory organisations.
You do not get rid of the state by making state organisations of new GP commissioning groups. You do not liberate GPs from the state by nationalising them.
There are three deep-set problems with nationalising GP commissioning. The first is that GPs have had six decades of working as small businesses and, for all of that time, they have worked alongside and not for statutory organisations. Over that period, generally GPs do not have a high opinion of the way in which statutory organisations have worked. They have looked at the public sector governance that hedges around the leadership of all of these statutory structures.
The strange thing about this policy is that the government agrees with GPs. They agree that state organisations are not the way to commission, yet the government appears determined to force GPs into them.
By the time the bill goes through Parliament, there will be a compulsory board, each member of which will want to make sure their voice is heard and stop GPs acting as small businesses. All of those members will see Parliament as the place to ensure their views are imposed on the commissioning organisations in England. They will not have to make a case to local GPs; the state will fix it for them. PCTs are being recreated before our eyes.
The second problem for the policy is that GPs, after 60 years of not working for the state, are unlikely to willingly work for it now. All GPs will be forced to become state commissioners, and while nearly all of them will pass that task on to another one of their number, these unfortunate few will have no alternative but to become state employees. What happens if they don’t? How is the state going to conscript GPs into doing something they have not wanted to do for over half a century? Liberation through conscription will not work.
Third is just a small, but important, point for the government. In the NHS, and the rest of the public service, the government has made it clear that it will publicly pillory all those public sector workers who earn more than the prime minister. Within days of the government coming to power, we saw a list of all NHS bosses working for statutory organisations who were earning more than this level.
But most GPs running these commissioning consortia will earn more than the prime minister, so the government may be creating another 200-300 statutory employees who will be pilloried over their earnings. By choosing not to enact the white paper, they would remain in the private sector and be spared the public’s indignant wrath.
So, this is the liberating offer to GP commissioners from the government: for the first time in 60 years, we are going to nationalise a GP activity across England. We will hedge round your ability to make decisions with a public sector governance model we believe has not worked in the past. As we think you will dislike this so much, we will make you do it. Finally, when you do it, we will publicly pillory you for what you earn.
There is no need for this. If the government understood public service organisations, it could free GPs from the state by suggesting they form private organisations called community interest companies in order to receive contracts from the state to carry out commissioning duties. Such companies - like foundation trusts - could not be bought by the private sector, nor could they distribute profits to shareholders, but they would be liberated from the state.