It is worth considering the role of GPs in, or should that be outside of, the NHS if we are to truly understand the significance of coalition health reforms
Blog / September 3, 2010 / 1 Comment
When the Secretary of State for Health, The Rt Hon Andrew Lansley, gave evidence to the Health Select Committee on 20th July this year it was the Conservative Chairman of the Committee that put the government’s NHS reorganisation into context: “We have all made speeches over the last few months, even years, saying the Health Service was not really looking for another reorganisation, yet after the Election we have the largest reorganisation for 60 years”. The Tory-led proposals are centred on the decision to hand over the £80 billion NHS budget to GPs and create GP Consortia that will commission and provide healthcare for their patients.
There are a number of reasons to be suspicious, if not highly alarmed, of the motives that underlie this most significant constitutional change to our National Health Service. The Coalition Agreement published following days of negotiations between the Tory high command and their soon-to-be Liberal Democrat partners declared their commitment to “stop the top-down reorganisations of the NHS that have got in the way of patient care”. The document did also fleetingly mention enabling GPs “to commission care” on behalf of their patients, however the role of the primary care trust (PCT) seemed safe and there was even talk of directly elected individuals sitting on the board of the local primary care trust (PCT). In his evidence to the Health Select Committee the Secretary of State said that it was not his intention “immediately before the Election or in the Coalition Programme” to abolish primary care trusts due to the invention of GP-led Commissioning, however this was the unintended consequence of these NHS reforms.
At the heart of his reforms, Andrew Lansley’s rhetoric is a determination to “entrench that sense of greater ownership on the part of patients”. How this ideal can be met by these sweeping fundamental reforms to commissioning is indeed dubious and raises some serious questions about the real effect of the Tory-led Coalition’s proposals to our National Health Service.
Any fundamental reform to the operating of the National Health Service will cost money and this cannot be the time to implement uncosted and unpiloted ideas thought up in Tory Head Office. The coalition’s commitment to cut NHS administration by one-third can only be at odds with another major top-down reform. There is also the issue of how the coalition’s commitment to increased democratic participation in the NHS can be met, now that they are abolishing the PCTs on which their directly elected board members were to sit.
It must be considered why the Secretary of State for Health would look to GPs to take control of the largest slice of the NHS budget. It is in the main agreed, even by the proponents of GP-led Commissioning, that GPs (although on the frontline of healthcare) do not possess the expertise to commission health services and would therefore need to build their own bureaucracy in order to fulfil their requirements. Some have suggested that many staff will drift from the abolished primary care trusts straight into GP Consortia in order to administer the new commissioning groups. Indeed, if the 151 PCTs in England were to be replaced by around 500 GP Consortia then it would be fair to suggest that the overall administration and commissioning costs to the NHS would increase; a larger number of commissioning groups would lead to unnecessary duplication of administration and to higher costs due to commissioning for smaller population groups. Of course speculation such as this is only necessary due to the complete lack of measured research and any attempt to pilot this scheme by the government.
Therefore the decision to utilise GPs for the commissioning of health services is not clear. However, it is worth considering the role of GPs in, or should that be outside of, the NHS if we are to truly understand the significance of coalition health reforms. Although the vast majority of GPs will earn most of their money from the National Health Service, they are effectively independent businesses with loose contractual arrangements with the NHS. Therefore, on the face of it, this government is handing billions of pounds of taxpayers’ money straight out of the NHS bank account into the hands of private organisations that will decide what services to provide for patients. Coupled with other coalition plans such as pushing NHS hospitals outside of the NHS into the private sector, health provision in the UK will be a lucrative business for any international company to move into with billions of pounds now in the hands of naive private GP-led consortiums seeking low cost health solutions in a private market that will dominate due to these reforms. Foundation Trusts will be re-classified and will not appear on the government’s books. What will be left of our NHS at the end of this £80 billion gamble is sure to look very different to what we have now.
Tory Health Ministers and their close links to private health companies were highlighted in the press prior to the general election and now their fundamental restructuring of the NHS will create a vibrant private market for such companies. Under their new system, with hospitals working outside of the NHS, every hospital will be free to dedicate as much time as it wants to private patients with the cap on what a trust can earn from private work removed. In addition, the removal of national waiting time guarantees alongside the brutal market-led environment being created, private patients will once again have a natural precedence in our healthcare system.
How our NHS cares for those with more specific healthcare needs, such as those with mental health problems, will once again become a postcode lottery. Whether you wait 8 weeks or 8 months for an operation will again be a matter of luck and not a guarantee or a patient right. All in all, the NHS that we know and rely on now will not remain as the British institution that Labour has made it over the last decade. It will be an NHS that works for the private sector and for profit. Patient care will once again take a backward step.
I have a small knowledge of GPs as commissioning consortia, though I'm only voicing my own opinion here.
The main strength that GPs bring is a long-term view. The GP as partner in an independent business is here for the long term (the salaried GP isn't – average tenure of a salaried GP is less than 2 years). The GP partner sees patient x and knows that decisions made today will affect the doctor, as well as the patient, for the next 10, 20, 30 years. So they make the right decisions. I'm sorry, but hospitals don't take this view because doctors and nurses move on. Sadly, PCT managers also don't take this view because they too have moved on to other specialities and other responsibilities. Independent GPs are best for patients, but they may not be the best at commissioning services.
6 years ago, before the last major reorganisation (merging PCTs from 303 to 152 PCTs), hospitals ran rings around PCTs because the hospital was much bigger and had all of the information. Hospitals took money hand-over-fist and attempts to move care closer to home didn't work. At present hospitals and PCTs are about the same size, and negotiations are a bit more balanced. But the proposed change (still 150 hospital trusts, but around 500 PCG-type organisations; also many district nursing teams will become part of their local hospital) tips the balance back in favour of hospitals.
My only hope is that this move by the coalition government is a prelude to the complete transfer of health into Local Authority control, with elected representatives in oversight and joined-up planning and implementation.
But many GPs strongly resist taking on the responsibility for commissioning, especially as they will inherit all of the poor decisions of the previous system, including long-term wasteful contracts for independent treatment centres, contracts with community care and hospitals that GPs have already said are not fit for purpose, most of the staff (because of TUPE) and only 1/3 of the money that PCTs currently have.
The most likely scenario is that GPs will simply take early retirement, leaving patients with no other choice but to go to hospital (in many cases, the most expensive route; and certainly not likely to give them the best care). Private companies will step in to fill the gap, but because they take a short-term view, the £billions will go in profits rather than proactive care. Tudor Hart will be proved right, 40 years on, as GP consortia step forwards in the most lucrative areas, and the deprived areas lose what little they already have.
Can anything be done?
Abolish PCTs by all means (if you must), but replace them at a local level with teams within the local authority. Let GPs focus on what they do best, handling 90% of the contacts between patients and the health service (nationally there are around 360million patient contacts in primary care and around 36million hospital episodes) and providing care for people with long-term conditions, close to their home. Avoid disruption at all costs, because the current system seems at last to be working.