Can GPs become agents of change, or will they remain gatekeepers?

Over 90 per cent of the annual public contacts with the NHS are with GP surgeries. GPs and their staff are the portal into the NHS for most people, whether GPs like it or not. Compared with other healthcare systems the NHS is unusual in offering people registration with a GP of their choice as a way of guaranteeing access to free healthcare.

Whatever dastardly things Lansley stands accused of by the BMA and others, he is not changing that fundamental point. Indeed he could be said to be building a logical development of a 60-year old system with which patients are familiar.

GPs are part of the British way of life. They have been around in some form since before the NHS. They feature in literature, films and television soaps. They are emblematic of the NHS for most people in the UK and those overseas who know about the NHS. They attract high levels of trust among the population, regularly outperforming politicians, journalists and even judges in most surveys of groups that people trust. The deeds of Dr Harold Shipman seem not to have dented that trust.

This trust has been established despite the fact that GP practices are small businesses that contract with the state for the provision of services and operate profit and loss accounts like any private sector NHS supplier of goods and services.

Unlike other private service providers they have managed to have their state remuneration negotiated by a trade union – the BMA – and convince the state that it should contribute to a generous pension scheme for them. Dr Finlay’s Casebook never made any of this very clear and most of the public and some MPs are unaware of these arrangements.

It is because GPs are businesses as well as doctors that they present an opportunity to those Ministers who recognise that an NHS with sluggish productivity and performance needs a dose of reform.

As a health minister, I certainly tried to exploit this business side of general practice in contract negotiations and with my 2006 push to apply practice-based commissioning (PBC) to all GPs. In that push I had the support of GP reformers and tried to use incentives to achieve progress; but I underestimated the capacity of PCT self-interest to thwart rapid change.

Andrew Lansley is simply learning from that experience and being more ambitious by removing the PCT roadblocks.

The Lansley reforms on GP commissioning consortia are a logical extension of PBC and far less reckless than many of his critics have suggested. Despite some good PCT commissioning, overall PCTs have lacked the muscularity to control hospital supplier induced demand.

They have had their chance and failed, as the health select committee recognised before the general election. Lansley has also inherited a substantial investment in primary care and community services, even though the latter’s productivity is poor overall. The 2003 GP contract incentivised change and clinical improvement in primary care and there have been innovative new private sector entrants.

Yet relatively few GPs have taken positive steps to link their own services to community health services in common facilities; and many were highly resistant to Ara Darzi’s proposals for polyclinics.

To date neither GP fundholding nor PBC have been able to effectively challenge the might of the acute hospital sector and produce large-scale changes in the way that services are delivered outside hospitals. Some will say too many GPs have relaxed into their financial comfort zone.

However, what the coalition is doing is throwing down the gauntlet to clinicians and giving them their head to produce significant change through clinically-led commissioning. GP consortia will need a lot of analytical and IT support to succeed and the mass of GPs will have to accept the leadership of their commissioning enthusiasts.

But the decision seems to have been made for GPs. They are to become change agents as well as gatekeepers and will work in new configurations, with people with different skill sets. We shall have to wait and see how many of Dr Finlay’s successors can rise to the challenge.