Primary care trusts should relinquish budgets to GPs right away, say NHS chiefs

BMJ 2010; 340 doi: (Published 29 June 2010) Cite this as: BMJ 2010;340:c3487
  1. Caroline White
  1. 1Liverpool

    Primary care trusts in England should start devolving commissioning to family doctors straight away, despite widespread uncertainty about transition arrangements and concern about a lack of accountability and relevant competencies among GPs.

    NHS chiefs issued the call to action last week in Liverpool at the annual conference of the NHS Confederation, which represents most NHS trusts, on the grounds that GP commissioning is likely to take some considerable time to set up.

    The policy, which will see hundreds of GP consortiums taking on some £80bn (€100bn; $120bn) of the total NHS budget and all but around 4% of commissioned care, is set to roll out in April 2012, when strategic health authorities will also have been dissolved.

    Nigel Edwards, the confederation’s acting chief executive, said, “One thing that policy people are often guilty of doing is to describe the end stage without describing the transition part that actually gets you there and for which there are significant risks, not least the money.”

    Anna Dixon, director of policy at the health think tank the King’s Fund, said, “There are lots of questions about how and whether GP led commissioning can actually work out in practice.

    “We often hear about the enthusiastic entrepreneurial GPs; but the reality is, for the majority of jobbing GPs, what will be their motivation to get involved with commissioning?”

    She added: “And what about conflicts of interest? We’ve just spent the past few years separating commissioning and provision, and now we are putting them back together again.”

    Simon Whale, managing partner at the strategic communications consultancy Luther Pendragon, said, “The government sees GPs as entirely fit for this role, whatever anyone else might think. But it’s fair to say that most GPs lack experience in commissioning.”

    But James Kingsland, who chairs the National Association of Primary Care, said that there were enough suitably experienced and enthusiastic GPs to take the proposals forward. Lack of leadership, of budget ownership, and of suitable tools had stymied previous attempts to put GPs in the driving seat of commissioning, he insisted.

    When pressed on the absence of detail on lines of accountability after he had delivered his speech at the conference, the health secretary Andrew Lansley promised that this would be clearly set out in the forthcoming health white paper, which is due to be published in July.

    Speculation persists, however, that the Treasury is unhappy at the prospect of GPs being responsible for so much public money and at the costs of reconfiguration, in a time of economic austerity, and potentially highly complex contractual arrangements.

    Mr Lansley’s current vision for health care is very similar to the proposals he set out in 2007 in Autonomy and Accountability in the NHS, said Dr Dixon. “I think it’s a plan that’s been formed in a different era, and the Treasury will have a lot to say about the proposals.”

    David Nicholson, chief executive of the NHS in England, admitted that the Treasury was worried about performance. “But so am I,” he declared. “[The plans] have got to get past our test first.”

    While not minimising the scale of the challenge ahead, he told delegates that Mr Lansley was “a man in a hurry” and that less navel gazing and more action were required of them.

    “We need to avoid turning into commentators [and] actually making things happen. The faster we do that, the more likely we are to get the results we need,” he said.

    He refused to give a timeframe for the transition period, because a complex set of negotiations, including with the BMA, were needed first, he said. But he added: “We can start now because it seems to me the only way we are going to learn whether we can get the best out of it is to do it.”


    Cite this as: BMJ 2010;340:c3487

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