Fifteen days on from the launch of the Con-Dem white paper ludicrously entitled Liberating The NHS, the reaction from most commentators and analysts has ranged from hostile to sceptical, while the TUC unions seem to be gearing up for a fight.
Health Secretary Andrew Lansley has more or less admitted to MPs that in throwing the white paper together he simply tore up the coalition deal, resulting in the unexpected decision to scrap the primary care trusts which the two parties had agreed to democratise.
There had been “a presumption” that there would be elections to primary care trust boards, he told the health committee: “But when you examine that structure, it seemed better to dismantle it.”
Lansley might almost have been speaking of the NHS as a whole.
If the white paper is carried through, the NHS in England is set to be broken up into a network of social enterprises and private providers “commissioned” by local consortia of GPs.
Both sides of the medical profession stand to lose from this, along with the remainder of the one million NHS workforce – who face being forcibly transferred to social enterprises outside the NHS or to foundation trusts which seem certain to be redefined as “off balance sheet” and therefore no longer NHS employers.
Hospital consultants and junior doctors have the most to lose in the immediate period ahead, being excluded from any of the decision-making, which will be exclusively in the hands and discretion of their primary care colleagues, but suffering from most of the cutbacks required to slash £20 billion from spending by 2014.
The very title of “NHS consultant” hinges on the career structure launched with the NHS in 1948.
Lansley’s plan could dismantle it, reducing England’s health-care system to another failed “market” of local free-standing hospitals and services like the system that collapsed at the end of World War II.
But GPs too face massive problems from the white paper if they allow themselves to be saddled with the commissioning role.
Perhaps the biggest problem is that they would be lumbered with driving through the quest for £20bn of “efficiency savings” – the biggest cutbacks ever imposed on the NHS.
Once there are no faceless primary care trusts or fat NHS bureaucrats to blame for the closure of local services and popular hospitals, or for the sacking of hundreds of nurses, doctors and other staff, then GPs will become the focus of local public anger.
The amount of extra cash they will be offered for the commissioning role will be enough to annoy campaigners – including GPs’ own patients – who will see it as blood money for axing services. But it will probably not be that much in the context of the additional work and responsibility that GPs will face if they take on commissioning in addition to treating patients.
The commissioning budget itself is also a trap for GPs – if they don’t sign up, they can be compelled to join a consortium. Lansley told MPs ominously that “if we are to have the scope of commissioning there must be unanimity.”
How many GPs can really be confident of reaching unanimous agreement from now on with a group of colleagues they may well not have chosen to work with?
We still don’t now what the minimum, target, or maximum size of a consortium might be, how they are to be established or who will agree the final set-up.
Current NHS figures suggest that if there are to be 500 or so consortiums this works out an average of around 80 GPs per consortium, and between two and five consortiums per primary care trust area (most of which are aligned with borough or county council boundaries).
The new plan leaves plenty of room for conflicts of interest, disagreements over clinical issues and ways of working, personal antagonisms, historic rivalries, geographical anomalies and other problems to crop up.
Consortia could quickly face divisive questions over which local services should be cut and which should stay – with some GPs on each side of the argument.
What would happen if some, a minority, can’t agree?
There is also the issue of resources. Lansley is now talking about putting in place arrangements to deal with the so-called “insurance risk” that some consortiums will face a steep local increase in health needs and run out of money.
But until now, the “risk pooling” was carried out throughout the NHS, which broke new ground in 1948 by establishing a system into which all taxpayers contribute according to their income, and from which all can access free treatment according to their health needs.
Breaking up this system will widen England’s already vast and widening health inequalities, while the localised control by GPs also opens up a near-certainty of an even more perverse “postcode lottery” with widely varying levels and availability of treatment from one area to the next.
It now seems from the latest proposals that GPs could face financial penalties if their consortium overspends. The idea is to use peer pressure to hold down spending, but it would also mean a GP could stand to benefit or lose financially, depending on whether they (and their consortium colleagues) agree to or withhold some treatment – creating a conflict of interest between them and their patients.
All this offers endless scope for tabloid exposÃ©s of GPs climbing into smart cars or pocketing big pay cheques while cutting local services or denying patients treatment.
Add to this the fact that as commissioners GPs will have to carry the can for any and every failure in local systems, just as primary care trust and strategic health authority bosses do now.
Every Mid Staffordshire-style failure in patient care will potentially be put down to the failure of the new system and the GPs running it.
It doesn’t have to be this way.
The GPs could instead join with their hospital colleagues, the health unions, other public-sector unions, the pensioners and community campaigns across the country to tell Lansley (with precise anatomical details) where to shove his white paper.
With all of the health professionals and most informed opinion ranged against him and no popular mandate for his policies, Lansley would struggle to get his Bill through Parliament.
Even if he forced it through, any cock-ups or cash crises that result would be clearly his problem, and not the fault of the GPs.
Lansley’s white paper is a daft plan, with more holes than a pair of fishnets – what would be even dafter is to sign up to implement it.
This article first appeared in the Morning Star newspaper.
Categorised in: Article
This post was written by John Lister