Do GPs have the stomach for the battle ahead?

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England’s health secretary has been putting flesh on the bones of his strategy for the NHS with almost indecent speed. After six years shadowing the role Andrew Lansley is a man in a hurry, and he seems to have transmitted some of that urgency to the department he now runs. Consultation papers are pouring out, and Mr Lansley himself is ever present, selling the story to any audience that will listen.

He does it well. When he’s in full flow you can see how the reform is meant to work and you begin to believe in it, just a little. It’s an unusual and even uplifting experience to see a politician who really wants to convince the doubters by the force of argument. Under the previous government these discussions often took place elsewhere to avoid parading differences in public, and policies appeared unrehearsed and at unexpected moments, such as Tony Blair’s promise in a television interview to match European levels of spending on health.

Mr Lansley’s basic pitch is that general practitioners provide an unexploited talent pool that, properly harnessed, will make the system work better. It’s an act of faith, like every NHS reform for the past 40 years. There’s little evidence, if that’s what you are looking for. But the belief that doctors are the best people to run the system has a long pedigree. In what some now see as the golden age of the NHS—before managers—responsibility was widely diffused. There was no “them and us”: under consensus management everybody realised that money was tight and did their best to spread it fairly. There’s probably a hint of false nostalgia to this picture, which was rudely shattered anyway by the introduction of general management into the NHS in 1984, by the Conservatives.

The second precedent for Mr Lansley’s reform is more recent: the introduction of primary care trusts in 2003. But their aim of putting GPs in the driving seat was quickly subverted. Managers displaced from health authorities found themselves chief executives; accountants became finance directors; and GPs were relegated to the next management layer down. Practice based commissioning was a largely unsuccessful attempt to recapture the original intention of the reform. It raised only modest enthusiasm, but it does provide the groundwork for the latest changes.

And there is, of course, another precedent for handing GPs money: fundholding. Mr Lansley is at pains to make clear that GP commissioning has nothing in common with fundholding, where general practices could retain unspent funds. Fundholding divided opinion, but by the end 57% of GPs were participating. It was introduced by the Conservatives without evidence that it would work and abolished by Labour without taking the trouble to see whether it had.

Rehearsing these snippets of history makes one realise how little there is that hasn’t previously been tried and that has usually been abandoned too soon to know whether it works or not. Mr Lansley’s defence for yet another reform is to argue that health economies are broke, everywhere, because most allow you to buy care and send the bill to somebody else. “You push the trolley to the check out, and the PCT [primary care trust] is there with the credit card,” he says. “That’s unsustainable.”

His pace, which seems headlong to some, is also deliberately chosen. Mr Lansley has attempted to combine sufficient pace, so that nobody could think his reform was drifting into the sand, with sufficient time to carry it out. Internal critics have been silenced. Soon after the coalition took office a rash of stories suggested that GP commissioning was a long term prospect, if that. The doctors weren’t ready; it wouldn’t happen. David Nicholson, the NHS chief executive, said so openly at the NHS Confederation’s annual conference in June. Those rumours have vaporised, but they have left in their wake the clear message from the managers that this is Mr Lansley’s policy and nobody else’s. The minor party in the coalition, the Liberal Democrats, have for the moment swallowed their doubts.

No GP can opt out of joining a consortium or of sharing legal and financial responsibility for its decisions. Practice income will be separated from commissioning income and allocated directly to practices by the NHS Commissioning Board. But variation of performance within the consortium is supposed to be managed by the members themselves. Poorly performing doctors who have survived every other management system unscathed are finally going to be weeded out by better performing doctors—not a very plausible scenario, perhaps.

Managing financial flows could be a headache. The traditional NHS method of balancing surpluses and deficits across the service by means of cash transfers cannot be used, because the idea is to incentivise those who generate surpluses, not penalise them by subtracting the money to bail out the heedless or unlucky. The management of financial risk will “evolve over time,” says the consultation paper on commissioning published on 22 July (BMJ 2010;341:c4015, doi:10.1136/bmj.c4015), which sounds a bit ominous.

In essence, Mr Lansley is betting that GPs can make better use of resources than PCTs and will show more initiative in pioneering new services. But there will have to be rules to ensure that all consortiums commission the basic services laid down by the Commissioning Board. Once that is done they may find that there is little left for new services except by cutting old ones. That probably means the acute sector, so the plan could set GPs against consultants, with the GPs holding much the stronger cards. In an era of tight money this could get messy.

So while the chairman of the BMA’s General Commissioners Committee, Laurence Buckman, talks up the need to “work closely” with consultant colleagues, the logic of the reform argues otherwise. Collaboration will not always do the trick, when the idea is to squeeze more from less. This is not a return to consensus management. The NHS has long ducked the need to reconfigure services, because it is painful. Have GPs the stomach for the battle?