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It’s unethical for general practitioners to be commissioners

BMJ 2011; 342 doi: (Published 10 March 2011) Cite this as: BMJ 2011;342:d1430
  1. Mark Sheehan, Oxford BRC ethics fellow and James Martin research fellow, The Ethox Centre, University of Oxford
  1. mark.sheehan{at}

The government wants to liberate the English National Health Service. By this they seem to mean to liberate the NHS from managers. The idea is that managing can be done by those who are already doing another job—general practitioners. It may be that the NHS is currently top-heavy, and it may not be as good as it might be. However, I have several ethical concerns about devolving commissioning responsibility to GPs.

There are two ways to ask how we should allocate NHS resources. Should we fund cheaper, less effective drugs, or better, more expensive ones? Here, the relevant considerations involve population level calculations—evidence of effectiveness, evidence of cost effectiveness, incidence, and projected demand. Alternatively, we might ask whether Mr Jones’s GP should decide to prescribe the drug that is less effective but cheaper, or the better, more expensive drug? Here, features of Mr Jones’s circumstances matter. Does he live alone? Can he cope with a few more headaches? Mr Jones’s GP can answer these questions because he knows him and his situation. The answers to these questions, given on the understanding that they are important for his welfare, now contribute to decisions about whether he gets the best treatment or not.

Who should decide? Who makes this decision makes a difference. When we think of the role of doctors, we include some reference to them focusing on what is best for us. When we disagree with our doctor, we disagree about what is best for us: the doctor-patient relationship is a negotiation of the differences between the doctor’s view of my best interests and my view of my best interests. Trust and confidentiality are precisely built on the understanding that my doctor has my interests at the forefront of his or her mind. If the GP is tasked with resource allocation, there is now an additional dimension to the decision: what is best for others.

Decisions about prioritising resources have to be made, but, given the role of doctors and the importance of trust, they should not be made by GPs. Like anyone else working in the NHS, GPs should be aware of these decisions and their difficulty. But, if anything, the GP is, and ought to be, the patient’s advocate in this process.

Currently, decisions regarding resource allocation are increasingly being made within a robust system by a range of people with the relevant expertise who are removed from the individual doctor-patient context. GPs and public representatives play a crucial role in the decisions and in their implementation. Once there is a policy, patients, together with their doctors, can appeal by showing that their case is exceptional. Here, in the individual funding request panel, the doctor is the patient’s advocate.

The trend in healthcare is to get the public involved, to let the people have a say—and GPs are closer to the public than many. The reality of resource allocation is that groups of individuals are in competition with other groups: people who need a hip replacement are in competition with people who need statins to lower their cholesterol. Asking patients who need a hip replacement whether hip replacements should be funded will yield the obvious response. Asking the same patients who should miss out on treatment to enable their hip operation may mean that “fat people” or “foreigners” go untreated.

Choice and empowerment are appropriate elsewhere but they are irrelevant in decisions about scarce resources. The principle of respect for autonomy suggests that we ought to respect an individual’s capacity for self governance, but NHS resource allocation decisions are between patients and cannot involve this principle. A baker has one loaf and three customers. Each customer has autonomously chosen to purchase a loaf of bread before they enter the bakery. In selling the loaf to any one of his customers the baker would respect that customer’s autonomy. His problem is precisely that he cannot respect all of their autonomous choices. He must decide which of the customers gets the loaf and so which person’s autonomy he should respect. He might sell the loaf to the first person into the shop, adopting a first come, first served principle of justice. He might divide the loaf into three so that everyone gets an equal but unsatisfying share. There are many more ways of approaching distributive justice here, each of which decides between autonomous choosers rather than respecting their choices. Resource allocation decisions in the NHS are necessarily decisions between patients, and so do not involve considerations of respect for patient choice. Instead, justice is the relevant consideration in deciding how to distribute resources fairly.

The current system of resource allocation is emerging as an increasingly functional process. There may well be issues of overmanagement to be resolved, but the solution to these problems is evolutionary, rather than a revolutionary overhaul that disbands the system in favour of general practice consortiums. The role of the GP as patient advocate is a crucial one and should not be compromised by giving GPs the additional role of resource allocation managers for the NHS.


Cite this as: BMJ 2011;342:d1430


  • I thank Dr Rebecca Cooper for her advice with this piece. I am also grateful for support from the Oxford National Institute for Health Research Biomedical Research Centre.

  • Competing interests: MS is ethics adviser to the Advisory Group for National Specialised Services (AGNSS).

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

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