It’s unethical for general practitioners to be commissionersBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1430 (Published 10 March 2011) Cite this as: BMJ 2011;342:d1430
All rapid responses
I really don't know what to make of Mark Sheehan's argument. On the
one hand he points out a potentially challenging conflict of interest
between being a patient advocate and allocating resources fairly, but then
he peppers his examples with highly unrealistic examples that undermine
His core conflict is less concerning than he supposes as individual
GPs are not allocating resources, that will be done by the consortia
giving GPs a stronger influence but not individual responsibility. But
rather more concerning for the relevance of his argument to the real world
is his assumption that "decisions about resource allocation are
increasingly being made within a robust system..." What robust system? The
one that has persistently allocated too much of the scarce resources to
hospitals rather than prevention or primary care? The one that has heaped
public money on the problem of health inequality without apparently making
any noticeable change in the measure of inequality? The one that has
allowed large variation in clinical activity unrelated to need to persist
He quotes another dilemma to illustrate the problem of dealing with
scarcity: the baker with only one loaf. In the real world, of course, this
resource allocation problem would go away on the next day as any sane
baker outside a centrally planned system would bake extra loaves so
everyone who wanted one would get one on day 2. Market systems find this
easy; planned systems find it impossible.
What matters in the real world is not the theoretical ethics of hard
situations, but the practical realities of real decisions. PArt of the
point of putting GPs closer to the resource allocation is that their
incentives will be more closely matched to the needs of patients so they
are more likely to do the right thing. Imagine, for example, that the NHS
has to balance the investment in hospital treatment with investment in
primary care and prevention (a real problem for the system especially for
patients with long term conditions). In the current system no GP has to
worry about the long term cost of treatment for his patients most of which
will be incurred in hospitals. In many individual cases the GP could
strive for more investment in primary care, but it will be a fight agains
a powerful hospital lobby and the individual GP will see no gain from the
saving made by the NHS. But if the GP is part of a group that holds the
whole budget, the decision about how to allocate the investment is much
easier: he sees the gain when the investment in primary care keeps the
patient out of hospital and saves the NHS a packet. So moving the GP
closer to resource allocation may well make it better. Doing a better job
for their patients doesn't seem to me to be such a significant ethical
I don't think we hit hard ethical questions in the NHS when we could
produce improvements for all by doing the resource allocation job better
right now. And we could do it a lot better.
Competing interests: No competing interests
I agree with Mark Sheehan . I also think he makes a bad case for a
The most celebrated ethical frameworks will have no problem with the
accumulation of the roles of commissioner and provider. The obvious
conflict is integral to the ethical posture, in the balance
-Between doing good while not doing harm;
-Between respect for the autonomy of the particular patient while
upholding justice for a population of patients.
While the balances above are specified in a principled approach, they
are also implicit and integral to the sort of judgements relevant to
virtue ethics and utilitarian frameworks.
However, the discomfort generated by this accumulation of roles
remains. It was already visible in the separation of commissioning and
provider arms of PCO's. Therefore it deserves attention.
The issue is about the role of justice and autonomy in the ethical
reasoning. Interestingly, there is an International meeting in Bochum end
of March about Justice and Modern Healthcare (http://www.ruhr-uni-
bochum.de/malakow/bmbf-conf/) and the European Society for the Philosophy
of Medicine and Healthcare also has Justice as the main theme for its
annual conference (http://espmh.org).
I approach this issue as the balance between patient centred, act-
related values (beneficence and non-maleficence) which are typically
negotiated within the relationship between competent people; against more
abstract, attitude-related values (autonomy and justice) which are
typically assessed against conceptual standards external to the private
relationship. The latter are aptly described as political issues.
It is a frequent fact that the pursuit of real improvements in human
life brings about deeper alienation from our core interests. Examples were
described by such diverse people as Karl Marx: while "he sees that
liberalism is a great improvement on the systems of prejudice and
discrimination which existed in the Germany of his day (...) such
politically emancipated liberalism must be transcended on the route to
genuine human emancipation." It is from here that "Marx argues that not
only is political emancipation insufficient to bring about human
emancipation, it is in some sense also a barrier." (Wolff, 2010, p. #2.1).
We may also look at Barry Schwartz' "Paradox of Choice" (Schwartz,
The Paradox of Choice, 2003) or his brilliant TED talk about this
(Schwartz, Barry Schwartz on the paradox of choice, 2006) to understand
how the current paradigm of individual freedom became a source of
alienation: the increase in opportunity costs, arising from the
multiplicity of choices, may achieve a negative net result for the
chooser, whatever the choice made. Thus, in exercising our freedom under a
model designed to improve it, we become alienated from our freedom, the
result no longer being a robust expression of the freedom we purport to
So what about GP's commissioning and providing for their patients? My
point is that it may tick all the boxes in everyone's ethical assessment,
it may be just, caring, considerate, expedient and whatever ethical tick
boxes one may wish for. But will the outcome of this process be a robust
expression of what General Practice is about? I really doubt it will.
Will it enhance the affirmation of human emancipation within the
encounter between doctor and patient - between two human beings meeting
under the ethos of a caring, therapeutic relationship? Ok, this is my
personal take on what General Practice is about, but please substitute for
your own. If this model enhances your core outcomes, then it is probably a
good model. If it does not, why are we accepting to have our core ethos,
our core attitudes and concerns, redesigned by stealth?
I believe we are heading for an efficient model, ticking all the
appropriate boxes, but producing an outcome in which we become alienated
from our core values and which we may have difficulty recognising as the
expression of what we are.
Schwartz, B. (2006, September). Barry Schwartz on the paradox of
choice. (K. Stoetzel, Ed.) Retrieved January 22, 2011, from TED.com:
Schwartz, B. (2003). The Paradox of Choice. New York: HarperCollins
Wolff, J. (2010). Karl Marx. In E. N. Zalta (Ed.), The Stanford
Encyclopedia of Philosophy (Summer 2010 ed.).
Competing interests: GP, tax payer, father of 5 individuals who will be served by whatever we put in place
Telegraph correspondent Liz Hunt wrote,
"Will we come to despise doctors as much as we despise bankers? This
is not as unlikely as it might at first sound. Bankers have been brought
low in the public's estimation by their greed. Doctors, or GPs to be
precise, are in danger of following them down the same path ... 
I remembered Liz Hunt's words of a year ago as I read correspondence
from Rob Michaels in Bournemouth in Saturday's Independent.
"We live in a sick society where the national average wage is around
?25,000 a year, yet simple GPs earn over ?100,000 a year, bankers earn in
a year what to other people is a national lottery jackpot, and now we hear
that banks pay less than 2 per cent in tax. If we don't make more of an
effort to create a fairer society in this country, we are looking at a
very bleak and unhappy future." 
Trust is all important: in these current circumstances I wonder if we
will be able to trust GPs to commission for a fairer society and nurse us
out of this malaise, back to health and a bright and happy future. I guess
that that Mark Sheehan would not think so ... and neither do I.
 GPs must work for health, not wealth. Are we on the verge of a
backlash against family doctors, asks Liz Hunt. Telegraph, 27 January
 Letters, The Independent, 12 March 2011
Competing interests: No competing interests
Mark Sheehan appears to breathe in a rarefied Ethox, oblivious to
real-life decision-making NHS processes.
Alistair Howitt corrects Mark's claims that GP-commissioning would
fatally contaminate their advocacy role towards the individual patient.
But does Mark not appreciate that every real-world candidate for
commissioner is flawed. Either they are so removed from the individual
patient that they haven't a clue about what matters, or they are so close
that they cannot act disinterestedly.
Every real GP has a waiting-room full of patients, each vying with
the currently-consulting patient, for the fullest attention and most-
effective medication. And in case that was too easily manageable, the GP
has also to decide whether the other 1500 patients on his list have
greater unmet needs than the particularly demanding or articulate patient
in the consulting room.
We GPs are already deeply mired in prescribing-incentive schemes that
aim for maximising population cover, contrary to individual best-
treatment. For example, NICE asks that we advocate the most cost-
effective 'low-acquisition-cost' statins, and not the best most expensive
one. Such decisions could be 'cleaned up' and taken out of our hands,
simply by banning the cost-ineffective options from NHS availability. But
who will sit on that arbitrating committee , if not jobbing GPs ?
We GPs are already mired in referral management schemes, where our
individual patient's need is compromised with the competing needs of
others. In my locality, some of my referrals for cataract surgery are
rejected. Apparently, patients with 'one good eye' have no need of
surgery. Who sits on the committee to decide such matters ?
In the kingdom of the blind, a one-eyed man is King !
Competing interests: GP, taxpayer, patient
The author completely misunderstands the proposed new commissioning
process. In his example of Mr Jones he suggests that individual general
practitioners will have the discretion and funding to make individual
decisions about individual patients. They will not and I, like most
general practitioners, would be aghast at such a notion for all the
reasons the author cites.
GP commissioning will be at a population level, with only a small minority
involved, in this area about 5% of GP's. In the consulting room the
reality will be that we will still be bound by resource allocation
decisions made elsewhere that we have little direct control over.
I share my colleagues concerns about the NHS reforms, but compared with
the current situation where Primary Care Trusts struggle to engage with
clinicians, I cannot agree that general practitioners acting as their
patients' advocates in commissioning services pose an ethical problem.
Competing interests: No competing interests