Guest editorial Wednesday 15 September 2010: The drawbacks and pitfalls GPs will face in commissioning

Irwin Brown of the Socialist Health Association looks at GPs’ risks under the proposed new system.

We like our GPs - a lot. So we tell opinion pollster after opinion pollster.

PCTs, by contrast, don’t like GPs: they refer far too many people into expensive secondary care when they could be treated far more cheaply elsewhere. They make appointments hard to get, so people go off to expensive A&E instead.  They have got away with working fewer hours, seeing fewer patients, whilst gaining the most financially out of the NHS reforms.  

GPs were against forming the NHS and refused to be part of it, staying as private contractors. Cleverly, they have avoided the constant reorganisations, political in-fighting and some of the bureaucracy. They act like employees when it suits them, but like contractors at other times - and have an excellent trade union despite not being employees.

The ConDems now propose to hand over our NHS to the one group opposed to it; nationalising GPs whilst privatising everything else.

Why on earth would GPs want to take on this responsibility?

There are many genuine policy questions about the wisdom of making GPs the commissioners of healthcare, controlling some £70 billion of public expenditure (£3,000 per family), although the public probably don’t care as they have no idea about what commissioning is and why it is important.

Commissioning and management – not easy, actually
In healthcare, demand always exceeds supply; so some very hard decisions on priorities or on how long you have to wait are necessary. Care also extends right across all kinds of public services and crosses every geographical border, which requires complex co-ordination and planning.

There are now many possible suppliers of care from whom to choose, offering different solutions. This is the stuff of commissioning; getting the right services from the right providers to get the best care at an affordable price.

There is a very strong case for involving GPs in the decisions about how resources are used since they see many patients and are well placed to understand the needs of the locality.  

To market, to market
The ConDems say that since they are canny small businesspeople, they will be very good at using market mechanisms to ensure care is provided as cheaply as possible – so long as they get a personal cut of the savings.  They must be innovative and efficient as they are businesspeople; not public servants.

Actually, under the current arrangements GPs are involved through mechanisms like (the admittedly highly variable) practice-based commissioning. When PCTs were set up, they all had to have special committees specifically to involve GPs - but generally these were ineffective and irrelevant.

Many argue that GPs are not involved because most of them choose not to be involved – if they had wanted to be enthusiastic participants they had the opportunities.

On the other hand, there are a few (and it is a few) highly vocal and entrepreneurial GPs who are convinced they can run the whole NHS the way they run their business; and they all know Mr Lansley.

We don’t usually give huge sums of public money to private businesses in the hope they will spend it wisely. Unless they are banks.

So GPs will have to be in consortia, which are statutory bodies, part of the inefficient public sector, bound by strict legal constraints. That probably greatly reduces the scope for the promised entrepreneurial spirit, innovation and risk-taking over which market advocates drool.

So the GP commissioning consortia will have boards, with outside people on them to keep an eye on things.  FOI will apply; every item of expenditure over £500 will have to be listed on a website; high salaries will be pilloried by local and national media; expenses picked over; procurement will be a nightmare paperchase etc.

There will be all the usual ludicrous, but possibly necessary, performance management, reporting and interference, which characterises public sector bodies.  They will hate this.

Blame the GPs
And here is the really clever bit.  Funding to the NHS is being reduced; cuts will be necessary; access will be restricted; waits will grow longer; premises will age; and some facilities will have to close even after massive local protests.  And the GPs as commissioners will be set up to take the blame.

With local government, we see this move all the time.  Funding is cut, so the Council has to cut services - but the blame sticks to the Council; not those who cut the money.

Currently, PCTs have to lead every consultation about any change to NHS services, such as downgrading an A&E facility, or having a regional centre for stroke care somewhere else, and they are always accused of slashing local provision just to save money.

So we put the GPs up instead to argue the case and hope their popularity gets them through – no chance, pickets outside the surgery. They will not like this.

And the commissioning is to be based on a one-year budget, with no reserves or contingency funds and no bail-out for any overspend even if it was entirely outside their control (maybe very harsh weather in March).  Managing one-year budgets in a way which allows every penny to be spent but with no risk of overspend is close to impossible.  

Tarnishing popularity?
Will GPs stay popular when they are accused of favouring one provider over another; of sending more patients to consultants they happen to know; or of awarding a contract to a private company who happen to offer some interesting incentives?

Not only are there possible conflicts of interest at every turn, there are also the public sector procurement regime and market regulation, which also gives many ways to transgress the rules (even innocently): wheel in the auditors.

Every one of the GPs in the consortia will carry their share of the blame for transgressions. They will not like this

Then there are mystery gaps.  PCTs are abolished, but the GP commissioning consortia will not be responsible for everything PCTs currently do.  Some bits of care, such as maternity, will not be commissioned by GPs and nobody has any idea how all these fragments will fit together.  Not to mention age-old gaps between ‘social’ and ‘health’ care.

When the cracks appear and disaster results the GPs will be the ones who carry the can as they are the local leadership of the NHS. They will not like this.

Parts of commissioning (for example designing care pathways) are interesting, and should have strong clinical input.  But most of the effort and expenditure in commissioning is in the boring bits like contracting, procurement, data analysis, loads of transaction processing like checking invoices.

The consortia will obviously outsource this stuff: either to private sector experts already poised to swoop, or to shared service providers they will have to create.  But if most of the actual work is not being done or overseen in any sense by GPs, then why give them the responsibility? Why should they want to take it?

It gets worse.  Having spent years staying outside the public sector, they become mainstream, having to pitch up at County Hall and give simple explanations in short sentences to local councillors or patient representatives, who will ask daft questions.

Local Health & Wellbeing Boards made up of local dignitaries will be able to poke and pry into what the GPs are doing, and even block needed changes for no good reason.  They will not like this.

And can all these GPs actually work together in the consortia without falling out and arguing? Can they actually agree on what is best? Will they agree to cuts in their patch, however strong the case? They are not politicians, who have to do this kind of thing and take the stick.

Anoraks among us will also raise all kinds of nasty techie questions, which still need an answer.  PCTs own lots of properties; have lots of contracts; may have debts and liabilities of all sorts.  They have access to capital from a number of sources.  Do the GP consortia take all these things on?

Anyone want a nice PFI-LIFT community hospital, now mostly used as expensive office space, underused and with high annual payments for 28 more years?

And who pays for the lavish new HQ of the Anytown GP Commissioning Consortia?

But can we, in time-honoured fashion, pay them for their trouble, give them a cut of any savings they make – top up their practice income with a nice little earner?  The price will be high.

Is there any price high enough to force every GP, every single one, to agree to go into business with colleagues they will probably rarely meet, taking collective responsibility for things over which they actually have little or no control?

If there is, the BMA will find it.