GPs will be compromised by commissioning

Holding the purse strings will be an unavoidable conflict of interest, says Dr Kailash Chand.

Health secretary Andrew Lansley's NHS strategy relies on GPs to make better use of resources than PCTs have and show more initiative in pioneering new services.

And there is, of course, a precedent: fundholding was introduced by the Conservatives without evidence it would work and abolished by Labour without taking the trouble to see whether it had.

What's different this time is that no GP can opt out of joining a consortium or sharing legal and financial responsibility for its decisions. Practices will be held accountable to ensure they live within their means. Practice income will be separated from commissioning income and allocated directly to practices by the NHS Commissioning Board.

But variation of performance within the consortium is supposed to be managed by the members themselves. Poorly performing doctors (financially) who have survived unscathed until now are finally going to be weeded out by better performing doctors (again, financially).

Over the decades, British general practice has adapted to change while retaining the respect of patients. GPs have clinical expertise and are also trusted to wield the pivotal power of referral.

In my view, GPs' role as advocates for their patients is compromised if they directly hold the purse strings. A service led by clinicians that is responsive to patients sounds good, but only if that prioritises clinical need and not business need. The commissioning structure being proposed is all about cash. GPs will be both purchasers and providers. This conflict of interest will inevitably tax their powers of disinterest.

The white paper says the new structure will ‘empower clinicians to innovate'. But GPs would undertake not only commissioning but also decommissioning – and that means rationing.

It puts GPs in the firing line for attacks from heartbroken relatives and a hostile media. There will be real or perceived conflicts of interest, which may undermine the crucial trust patients place in the profession.

GPs are providers of care, in their own practices and also often as part of provider companies, delivering services in the community.

Consider this: GPs may commission services provided by their own surgery or by a community company they are part of – raising income for themselves or their surgery. And what about a GP consortium decommissioning a service for its patients in order to come within budget for the financial year, and passing on some of the rewards for its cost-efficiency to its practices?

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?

Dr Kailash Chand is a retired GP and chair of Tameside and Glossop PCT. These are his personal views.