GPs should not be set referral limits or caps, but must be free to decide NHS spending priorities, two of the biggest supporters of the commissioning reforms have told HSJ.

NHS Alliance chair Mike Dixon and National Association of Primary Care chair Johnny Marshall spoke following the decision of the groups to form a “coalition” and consider merging.

They responded to high profile concern among GPs about whether involvement in commissioning, with the need to allocate and stick to budgets, will conflict with their duty to individual patients.

Royal College of GPs chair Clare Gerada sparked debate when she told HSJ that GPs were being asked to agree to limit referrals to particular numbers, that they should seek legal advice, and that GPs should “not be involved in rationing decisions”.

Dr Dixon and Dr Marshall, responding to the issue, accepted some emerging clinical commissioning groups had made such agreements. They said it was either because they applied strict limits at times of financial problems, as primary care trusts had done, or because they were in early stages of development and had yet to learn better methods.

Dr Dixon said: “A referral cap is in itself an admission of failure [and shows] you haven’t got enough ownership for people to live within the [financial] boundaries of what you’ve got. By all means set your own cap but you shouldn’t have the cap set without you.

“It is terribly primitive – it is an admission of failure.”

Dr Marshall, who is stepping down as NAPC chair in January and is leading the group developing the coalition of the two organisations, said: “Having a number simply reflects an old way of thinking. What the most well advanced groups are doing is looking at quality based pathways of care.”

However, they said GPs had to take responsibility for budgets, including prioritising some treatments and patients over others.  Dr Dixon said it would mean GPs becoming “fully paid up members of the NHS in a way we certainly weren’t before… we were almost people who worked up activity in order to increase our income”.

He said many GPs supported it but some “are saying we don’t want to take responsibility because our role is with the individual patient”. Dr Marshall said: “But that just doesn’t wash if you want to be part of the NHS.”

Dr Marshall said GPs should decide priorities in a “proactive” way and with other clinicians and the public. He said: “The reality is prioritisation going on all the time and there isn’t an open and honest debate with the public about the need to make wise investment of those resources, and cut out some of the waste.”