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At the heart of general practice since 1960

GPs' biggest challenge now: the best care, most cheaply

GPs are now little more than an intermediary between the patient and NHS rationing, writes Kailash Chand.

When I joined general practice almost 30 years ago, it was frequently and justifiably described as the jewel in the crown of the NHS. We as GPs led primary health care teams which provided comprehensive, continuous, coordinated, and personal care for registered patient populations, and exercised an important gate-keeping role by regulating patients' access to more sophisticated and expensive facilities in secondary care and acted as a patient's advocate.

Now, with the advent of the coalition Government's Health and Social Care Bill the GP'sadvocacy  role fundamentally changes to an intermediary between the patient and NHS rationing. Once GPs hold their own budgets, each patient becomes a unit of rationing or possibly a business prospect. GP commissioning creates a perverse incentive to focus on financial gains rather than high-quality care. Will GPs remain the best advocates for patients or will they be running a profit-based business? There is a serious conflict of interest in commissioning NHS services while benefiting financially from such provision, or worse, from withholding a service.

The 'any qualified provider' clause will encourage clinicians and nurses to enter the marketplace to try their hand at turning tax-payer's money into profits through a ‘right to provide' initiative. This will allow specialist healthcare professionals access to start-up funds to set up their own organisations, which would exist outside the NHS but be contracted to provide, essentially cherry-pick, health care for profit. A consortium does not have a duty to provide a comprehensive range of services, but only ‘such services or facilities as it considers appropriate'. In making these arrangements, commissioning consortia will not be permitted to exceed their allocated annual budget. Across the country, consortia will behave differently, leading to a fragmentation of the NHS. In a prevailing tight financial climate, the decision-making process of the consortia, particularly when it comes to the rationing of clinical services, will have no accountability to other NHS organisations or indeed to the public that these consortia serve.

Further, the reforms will solidify the arrangements for clinical commissioning groups to pick and choose patients and services. It will no longer be mandatory to provide comprehensive care at primary care level, and the bill if enacted, will allow commissioning groups to recruit members, and introduce charges and private health insurance, as well as enter into joint ventures with private companies to outsource most work to private companies with vested interests, beyond the scope of full public scrutiny. Competition on the basis of cost to the commissioners and profit to shareholders will become the mantra, and with some parts of the traditional district general hospital facing de-commissioning, the landscape of secondary NHS care is likely to change for good. This has led to opportunities for some private companies; Integrated Health Partners has proposed a joint commissioning venture in which consortia will have a 20% share. In what appears to be a serious conflict of interest, Andrew Lansley, England's health secretary visited the partnership and praised its success. Not nearly of Cameron-Coulson proportions, but nonetheless a pointer of which direction of travel he wants to take the NHS, and perhaps a lack of judgment on how the majority of NHS stakeholders would feel. A consortium will only provide ‘such services or facilities as it considers appropriate'. In making these arrangements, commissioning consortia will not be permitted to exceed their allocated annual budget. Across the country, consortia will behave differently leading to fragmentation of the NHS, and in a tight financial climate decision making of consortia's particularly when it comes to rationing of clinical services will have no accountability to other NHS organisations or indeed to the public these consortia serve. 

I think we're heading towards the perfect storm. For GPs to take on a commissioning role which has not been tried or tested anywhere let alone in the NHS, in a climate of financial tightness, higher patient expectations, no open debate about rationing, and increased demand, detracts from the essential role that GPs play in maintaining the health of the nation. Besides, postcode medical treatments can only get worse as GPs compete for business. Many GPs will themselves get dogged by the rights and wrongs of commissioning, and the ethics of what is the best treatment for their patient and what best fits their financial envelope.

The alarming consequences would be a field day for the tabloid press who would not hesitate to portray GPs as fatcat practitioners, with half a mind always on the golf course, might take to the new order and painting the entire profession with the same brush. The HSJ recently wrote that experiments with letting family doctors handle the purse strings revealed that cash intended to pay for treatment was being redirected towards equipment for GPs' own surgeries, which can be tantamount to lining their pockets. Add in financial engineering to convert clinical savings into dividends, and you can see why the media would say that some doctors will get very rich, very quick.

General practice will face many challenges with the near total penetration of market-based, managed care into the NHS, but the biggest challenge will be to continue practicing traditional ethical medicine, providing care for the greatest number of patients, with the least expenditure of scarce healthcare resources.

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