Keep GPs in the driving seatBMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d3382 (Published 01 June 2011) Cite this as: BMJ 2011;342:d3382
- Nigel Hawkes, freelance journalist, London
As it struggles to rescue its health reforms, the government is in danger of getting the worst of all worlds. By attempting to appease its critics and reconcile its internal differences, it risks retreating to a system of entrenched medical interests each doing their own thing and spending their spare time arguing over resources.
How best to get the highest quality healthcare at the lowest cost? For 20 years we have worried at this particular bone. Splitting purchasers from providers, introducing choice and competition, and elevating commissioning to a central role have been the levers of change. They have all proved weaker than their originators hoped but—if you squint—you can discern some evidence that in recent years the English NHS has performed better than those in the devolved administrations, which have followed a more collegiate organisational style.
Health secretary Andrew Lansley’s aim was to make the levers stronger by increasing competition and improving commissioning. But every step in this 20 year evolutionary process has been fraught with difficulty. He therefore needed to do it in a way that did not animate its opponents or revive old arguments. His failure to do so risks setting back the clock—so much so that the architect of the Blair reforms on patient choice and provider competition, Professor Julian Le Grand, now argues that the best option for the government is to abandon the bill altogether.
What would be lost? Mr Lansley, perhaps. But of the actual contents of the bill, the move towards increased competition appears already to have been abandoned, or diluted to homoeopathic concentrations, while GPs who have volunteered to become commissioners have been left in the lurch, to their anger and frustration. They have stuck their necks out, or put them on the block, to use the words of Dr Michael Dixon, chairman of the NHS Alliance. “Suddenly now they are going to be told to go home … they are using words like betrayed.”
They are learning the hard lesson taught to generations of would-be reformers in the NHS: ministers propose, but do not dispose. Take the lead if you must, but watch your back. You may be doing exactly what the health secretary ordered but if it causes too much fuss, you will be abandoned. The survivors will be those skulking in the back row, doing things the way they have always been done. They cannot sack you for that.
Since the purchaser-provider split, commissioning in England has been undertaken, in succession, by district health authorities, health authorities and GP fundholders, primary care groups, primary care trusts (halved in number in 2006), and practice based commissioners. All have, on mature reflection, been found wanting. So it is a triumph of hope over experience to believe that there is a model of commissioning yet untried that will unleash a mighty wave of innovation and change in the NHS.
The truth is we have no idea if GPs can give commissioning the backbone it has always lacked. The chances will be lessened if the advice of the Commons Health Select Committee is followed and commissioning becomes a cooperative enterprise, involving hospital consultants, nurses, a public health expert, a social care representative and a local councillor. The prime minister, David Cameron, has hinted he favours this prescription. Nick Clegg, in his speech on 26 May, made it clear that he does.
What’s wrong with it? It would keep the royal colleges happy. Many consultants can’t bear the idea of GPs in the driving seat. Take Dr Andrew Bamji, a feisty rheumatologist from Queen Mary’s Hospital Sidcup, who responded to a recent article in Pulse by commenting: “I have (as a hospital consultant) long held the view that one of our roles is to tell GPs what services they should be buying—and why. If all healthcare planning is to exclude hospital doctors we might as well all resign.” He goes on to suggest that GPs have finally escaped the attribute of being doctors “who have dropped off the hospital ladder, but it is foolish of them in the extreme to seek their revenge in their happiness at the destruction of consultants’ power.”
Dr Bamji has the admirable quality of saying exactly what he thinks, but in this case it is also what a lot of other consultants think. The problem with this view is that you can’t have a purchaser-provider split and be on both sides of it at once. Hospitals are unequivocally providers. GPs are too, but their interests are less bound up with the preservation of a particular service or hospital. Their focus is on patients, not specialisms.
Commissioning is only worth the candle if it can create change. In private industry, 60% of innovation is driven by providers falling out of the market and being replaced by others. Only 40% is internally generated. Commissioning needs to make possible this kind of disruptive innovation. But that means hard decisions, less likely to be taken if commissioning consortiums are not given the maximum freedom possible and the minimum number of constraints.
The NHS Confederation seems to agree. In its new paper The Right Reform for Patients it argues that while there should be effective input from specialist clinicians, clinical advice should not be confused with governance. “So there should not be a requirement to include representatives on the boards of the commissioning consortia from the acute sector or the royal colleges … there is merit in maintaining a strong primary care perspective in the commissioning process.”
Commissioning has so far proved a weak reed. Commissioning without effective competition will be weaker still. To believe that GPs are bloody minded enough to make it work is a long shot, but it is one part of Mr Lansley’s plans that deserves to be preserved.
Cite this as: BMJ 2011;342:d3382