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Cock-up or conspiracy, commissioning will bring general practice's golden period to a close

As a rollercoaster year comes to an end, Jobbing Doctor ponders the future - and doesn't like what he sees

As a rollercoaster year comes to an end, Jobbing Doctor ponders the future - and doesn't like what he sees



The beginning of the end is here.

Jobbing Doctor's career has neatly straddled the golden period of general practice. It started with the development of general practice Vocational Training Schemes (which were actually voluntary when JD started in practice) and will finish with the implosion of traditional general practice.

There have traditionally been people who have been the harbingers of doom, from the traditional fortune-tellers of Grecian Antiquity right through to the modern day. There is always the temptation to be gloomy when you are approaching the end of a career, so I have tried to avoid that - telling myself that the Government and the enthusiasts have got it right, and the Jobbing Doctor is a curmudgeonly old buffer who cannot move with the times: a veritable Cassandra. It is me who has got it wrong, and I should depart, gracefully, from the scene.

I don't think I'm being too paranoid about this, but everywhere I look I see the forces of corporatist brutalism circling overhead, whether it be the GMC with their plans for revalidation, or the Royal College with their increasingly worrying e-portfolio or the PCTs with their appraisals.

No, these are mere peccadillos when it comes to the whole future of general practice as an entity.

This may seem too unsuitably apocalyptic as a comment, and indeed I may be reading too much into the future, extrapolating unnecessarily - but this is how I read it.

We embark next year on a process that has not been piloted, where we will be expected to perform tasks and make decisions that, frankly, we are not equipped to do. We will be expected to manage a vanishing budget, with much of it already committed to wasteful schemes and unnecessary spends where the money could be made to work much better.

A recent international report still states that we have the cheapest health spend as a percentage of GDP compared to any First World country. We also have the highest rates of satisfaction for our healthcare system. That ought to be a recipe for leaving things alone - 'if it's not broke, don't fix it'. But it isn't.

We have now embarked on one of the most fundamental changes in healthcare management that has occurred since the inception of the NHS. I want to know what is driving it, and why we need change. Is it cock-up or conspiracy?

I am a lifelong cock-up theorist. I generally feel that managers and politicians haven't got much of a clue as to how general practice works. All changes they generate usually end up in a mess, and the law on unintended consequences tends to come into play. If it were simply that, then I could be more sanguine.

But this is a conspiracy, and conspiracy when combined with cock-up results in chaos. Chaos is what we can expect in the next two years.

The driver for all these changes is the introduction of private medicine into the NHS. That is the whole underpinning of all these changes. The coalition Government are just continuing what the New Labour administration started.

So, over the next few months we shall see a lot of posturing and selling of these changes. The enthusiasts will be rolled out to support and encourage. The cynics, like me, will continue to warn about the risks. The huge majority will just shrug their shoulders and try to cope with the new changes.

Meanwhile, my retirement date will be more to do with this than my mortgage.

Yes, I've had the best of it.

The Jobbing Doctor is a general practitioner in a deprived urban area of England.

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