GPs are handed sweeping powers in major shake up of NHS

BMJ 2010; 341 doi: (Published 14 July 2010) Cite this as: BMJ 2010;341:c3796
  1. Jacqui Wise
  1. 1London

    The NHS in England is to undergo a radical reorganisation, with GPs commissioning most services and the abolition of primary care trusts and strategic health authorities.

    The government’s white paper contains far reaching proposals that devolve power from central government to patients and doctors. Reaction to the proposals has been mixed, with one concern being whether GPs will be given enough support to take on their new expanded role. Another worry is that such large scale change is risky at a time when huge efficiency savings have to be made.

    A key plank of the white paper is that all general practices must join a consortium that will commission the majority of care for their patients. It is anticipated that GP consortiums will hold around 80% of the total NHS budget. The white paper states that the new model is “neither a recreation of GP fundholding nor a complete rejection of practice-based commissioning.”

    There will be no fixed size for the commissioning consortiums, although the white paper says that they must be big enough to manage financial risk and allow for accurate allocations. The aim is for a shadow system of consortiums to be in place in 2011-12, with primary care trusts supporting practices during the transition process. GP consortiums will take on responsibility for commissioning in 2012-13 and will take full responsibility from April 2013. At this date all 152 primary care trusts will be abolished.

    An independent and accountable NHS Commissioning Board will be established, which will hold the consortiums to account for their performance and quality. It will also allocate NHS resources to the consortiums, set commissioning guidelines, and commission dentistry, community pharmacy, primary ophthalmic, and maternity services. This will pave the way for the abolition of the 10 strategic health authorities in 2012-13.

    Launching the white paper, the health secretary, Andrew Lansley, said, “For too long, processes have come before outcomes, as NHS staff have had to contend with 100 targets and over 260 000 separate data returns to the department each year. We will remove unjustified targets and the bureaucracy which sustains them. In their place we will introduce an ‘outcomes framework’ to set out what the service should achieve, leaving the professionals to develop how.”

    Mr Lansley said that the NHS needed to be liberated from the old command and control regime. All NHS trusts will become foundation trusts, freeing them from the constraints of top-down control and putting more power in the hands of their employees. Any willing provider would be allowed to deliver services to NHS patients, provided that they delivered high quality care.

    He said, “Our aim is to create the largest social enterprise sector in the world. But it is not a free for all.” He said that Monitor, the regulator of foundation trusts, would become an economic regulator to ensure that the services being provided are efficient and effective—and that every area of the country has the NHS services it needed to provide a comprehensive service to all. The role of the Care Quality Commission would also be strengthened to safeguard standards of safety and quality.

    Many of the changes in the white paper need primary legislation. A health bill will be introduced this autumn.

    Chris Ham, chief executive of the health think tank the King’s Fund, said that the white paper was one of the biggest shake ups of the health system since the NHS was established. He said, “Giving GPs responsibility for commissioning care and managing NHS budgets should result in services being more closely aligned with patients’ needs. But, while some GPs will seize this opportunity, many others may be reluctant to come forward and lack the skills needed.” The deadline was very ambitious, and to achieve it would require appropriate support for GPs to be put in place, he added.

    Steve Field, chairman of the Royal College of General Practitioners, said, “GPs work at the heart of communities; we know our patients and we understand their needs. If this is properly delivered and properly resourced, patients can expect to receive far more personalised services, focused on their individual needs.”

    Jennifer Dixon, director of the health policy charity the Nuffield Trust, agreed that the scale of the challenge was huge. “GP commissioning consortia will need huge investment into their management if they are to transform themselves into organisations that are able to deliver and commission—at scale—high quality care for patients, while challenging large hospitals,” she said. She added that it was risky to reduce central government control given the urgent need to make efficiencies in today’s economic climate.

    The white paper also includes proposals to create a public health service. Local authorities will employ a director of public health, who will have a ringfenced public health budget to allocate. Local authorities will also be given control over local health improvement budgets and the power to agree local strategies to bring together the NHS, public health, and social care.

    The coalition government said that cutting bureaucracy by abolishing primary care trusts and strategic health authorities will reduce NHS management costs by more than 45% over the next four years. However, the social policy think tank Civitas rejected the claim, saying that with around 500 commissioning organisations replacing primary care trusts transaction costs, for example, would increase. Also, many people will end up reapplying for their old jobs in the new structures.

    James Gubb, director of the health unit at Civitas, warned: “The reality is that considerable resources will need to be devoted to the restructuring by creating new organisations, laying people off in PCTs [primary care trusts] and recruiting new staff at GP consortia, working out the right blend of risk and reward for GP consortia, creating new accountability frameworks, and implementing new formulas for distributing resources.”

    Another major strand of the reforms is to give patients choice and control over their care and treatment and choice of any willing provider. They will be able to choose a named, consultant led team for elective care and will have the right to register with any general practice regardless of where they live. Patients will also have much greater access to information, including the power to control their own patient record.

    A new NHS outcomes framework will be issued later this year. This will contain national outcome goals against which the NHS Commissioning Board will be held to account. The National Institute for Health and Clinical Excellence (NICE) is to develop a set of 150 quality standards that will eventually be incorporated into the framework.

    Hamish Meldrum, chairman of BMA Council, said, “Although giving patients more information about their care is to be encouraged, we need to be very careful about how we use any outcomes based data to ensure that it is meaningful to both the profession and patients.” He added, “Plans to link outcomes to NHS funding will need to be carefully thought through to ensure that any payments are a true reflection of the activity and cost involved.”

    Ian Gilmore, president of the Royal College of Physicians, said, “We are particularly pleased that the crucial role of national clinical audit will be strengthened and that GPs will again be able to refer patients to individual hospital specialists in line with the patient’s wishes.” But he warned that commissioning groups must work collaboratively with specialists to develop integrated care pathways.

    Nigel Edwards, chief executive of the NHS Confederation, which represents over 95% of NHS organisations, said, “The transition of commissioning functions to GPs will require careful management over the next three years to ensure that the handover of responsibility is smooth and that patient care is not affected. It will also be essential to avoid a talent drain from primary care trusts; now is the time for strong leadership at a local level.”

    Karen Jennings, head of health at the public service union Unison, strongly criticised the plans. “Far from liberating the NHS, these proposals will tie it up in knots for years to come. They are a recipe for more privatisation and less stability. Handing over £80bn [€96bn; $120bn] to untried, untested, and probably private sector led consortia is reckless,” she said.

    David Furness, from the Social Market Foundation, a UK think tank, said, “At best this will be a waste of time, at worst a waste of money.”

    He added: “Commissioning health care is very difficult and needs a specialised organisation to do it. GP commissioning risks handing real control of the NHS to vested interests on the provider side, as GPs simply won’t have the muscle to drive through change.”

    Key proposals in the government’s white paper

    • All GPs to join a local commissioning consortium

    • GP consortiums to take full financial responsibility from April 2013

    • Patients given right to register with any general practice

    • Patients to be able to choose between consultant led teams for elective care by April 2011

    • All NHS trusts to become foundation trusts by 2013-14

    • NHS Commissioning Body to be established in April 2012

    • A new public health service to be led by local authorities

    • Healthwatch, a new independent consumer champion, to be established

    • Monitor to become an economic regulator

    • Strategic health authorities to be abolished in 2012-13

    • Primary care trusts to be abolished from April 2013

    • Reduction of NHS quangos by at least a third

    • Personal budgets to be expanded

    • NHS outcomes framework to be fully implemented by April 2012

    • NICE to produce 150 quality standards by July 2015


    Cite this as: BMJ 2010;341:c3796