Primary care duped: the government’s bill will wreck the NHS

How have we got into such a mess? How can people who have devoted the whole of their working lives to the principles of the NHS been so compliant, misled, or trampled on (depending on your perspective) in the bungled reorganisations triggered by the Health and Social Care Bill that is now before the upper chamber?

I have worked for the past 12 years as a general practitioner in Health Secretary Andrew Lansley’s backyard, setting up a new general practice to serve the people arriving in the green field development of Cambourne (population 9000 and aiming for 11 000). The practice has championed holistic care with the autonomy of the patient, a right to information, and respect for the patient’s expertise at the heart of the service.

I chaired the local medical committee, and until recently I was vice chair of our emerging primary care consortium as it morphed into a clinical commissioning group.

So I have to put up my hand and say that this mess is my fault. When our primary care trust began to discuss the coming of financial doom in the NHS a few years ago, I felt the shudder in the first class lounge; I saw the whisky glass slide across the polished table and I knew the unsinkable NHS, of which I was so proud, would inevitably founder if we did nothing. I drew graphs and found apposite pictures to entertain my general practitioner colleagues and their practice managers. I attempted to raise awareness of the threats of soaring spending as our population ages, as our scientists become more expensively ingenious, and we all become obese and develop diabetes but survive longer. Something had to be done.

Our trust was among the first in the country to recognise that a radical change was needed. Clinicians had to join with managers to improve efficiency. Primary care had to join with secondary care to agree on pathways that served patients better for lower cost. Our trust invited general practitioners to lead, and we responded. We even met Andrew Lansley to explain what we were doing. We drew practices together and published performance figures to ourselves and issued challenges to explain anomalies. We gave our time because we believed in what we were doing. And we were succeeding: costs were falling, and efficiency was improving. Respect between managers and general practitioners and between general practitioners and consultants soared as we learned of each other’s expertise.

But then the bill came. We were invited to become so called pathfinders, and we trotted along obediently because we were already leaders. Then we began to understand the proposed legislation. Primary care trusts were to be abolished and pathways were to become illegal, sacrificed to “any willing provider” who would trample across them, waving competition legislation on behalf of their shareholders. The secretary of state was to become a promoter of the provision of health services rather than responsible for them. “Setting the NHS free” was the slogan, but it was really about setting the politicians free. General practitioners were to take over the secretary of state’s responsibility and most of the jobs previously done by primary care trusts.

We were being set up. Who among us, even the enthusiasts, had the necessary skills? Who had the extra time needed? How would the complexity of all the new committees, watchdogs, boards, clusters, consortiums, and providers be serviced alongside the day job? Oh, and by the way, we were also to save £20bn (€23.9; $31.6bn) while we were at it.

We had had no warning before the bill that a substantial top down reorganisation of the NHS was to be imposed on us. Indeed, the election manifestos had promised the opposite. As a pathfinder, I went to Downing Street to meet David Cameron, Andrew Lansley, and the chief executive of the English NHS, David Nicholson, and told them that I thought the reforms were unworkable. They listened politely. I wrote to my executive committee colleagues on our commissioning group to urge withdrawal from pathfinder status, but my call to the barricades fell on deaf or reluctant ears.

Our early enthusiasm for protecting the fundamental ethos and values of the NHS led us into collusion with the bill. By the time the professions really understood the bill much of the damage was already done. Many experienced and dedicated primary care trust managers saw what was coming and looked for other jobs; those who remained colluded with the so called reforms in the hope of continuing employment—and the demolition continues.

Now we stand baffled in the wreckage like a householder who has recklessly allowed his plausible but incompetent builder to bash out a load bearing wall to improve the view but instead has brought the whole edifice to the point of collapse. Let us put down the sledgehammer, get rid of the bill, and bring in a structural engineer to stabilise our finest institution.