In the whole debate about the Government's Health and Social Care Bill there has been one assumption that has rarely been challenged, even by many of the Bill's opponents. I heard it repeated on the radio just this morning: ‘GPs are best-placed to know and represent what the needs of their patients are.'
This is the unquestioned assumption that lies behind the whole idea of GP-led commissioning and I would like to argue it is false.
The first thing to ask is what precisely do people mean when they say GPs are ‘best-placed' to know what's best for their patients?
GPs, it is assumed, are closest to patients, and therefore know best. I'm not sure that was ever really true but in today's world it is a misleading image. There are lots of reasons GPs have only a partial, probably biased, knowledge of ‘their' patients.
The patient populations in urban areas (the majority) are subject to sometimes huge churn rates - in excess of 25% a year.
GPs only see a fraction of those who are registered with them on a regular basis, let alone those that are not even registered with a GP, and in group practices patients often see different doctors each time they come in.
Ultimately, GPs are generalists. Whilst many make an effort to keep up with developments across a range of specialisms, with the best will in the world they can only hope to know a fraction of what is happening.
True, more treatments can, will and have moved into the community, especially for chronic conditions like diabetes, but there are limits. A lot of more and more specialized treatments are also available, about which most GPs have what is frankly not much more than an intelligent layperson's knowledge. For patients with chronic or acute specialist problems, their consultant is far more likely to understand their needs than their GP.
Getting proper epidemiological, demographic and other data collected and analyzed about a specific practice's patient population is beyond the means of any singleton practice, most group practices and I suspect most CCGs. Some GP group practices do try, and even carry out consultation exercises with patients, but these are a minority (I have never, ever, been consulted in my 59 years).
Finally, on the knowledge front I have yet to see anyone explain how precisely the knowledge of patients needs that individual GPs may have gets translated from individuals, through group practices thence aggregated into CCGs preferences – and then negotiated between multiple CCGs and multiple providers.
Before moving on to my second main point, there is one other issue that has been largely neglected – money. At the moment, distribution of funds down through the system is population/area-based and draws on the sort of epidemiological and demographic data mentioned above.
The new funding system for CCGs seems to be being based on patients (not the same as population) with some guestimated ‘population' factors. Anecdotal evidence I've heard from some PCT areas suggests this will lead to wild variations – either upwards or downwards – in the funds available to specific CCGs.
There is one other sense that GPs are somehow seen as best-placed to represent patients interests, and that is that they somehow are closer to those interests and not subject to what is called ‘producer capture' that supposedly afflicts hospital doctors and NHS managers. GPs are supposedly more ‘on the side of' patients.
What this suggests is that GPs are patient-centered ‘knights' (to use Professor Julian Le Grand's terminology) and that hospital doctors and managers are self-interested ‘knaves'. Even just spelling out this assumption makes it obvious how absurd it is, but it is nevertheless there lurking in the background.
GPs are no more knightly or knavish than anyone else. It is true that public service generally, including health, tends to attract people with generally more of a public service motivation– there is ample survey evidence to support this. It is also true that the institutional and culture context of public service tends to reinforce these values (just as the institutional and cultural context of a hedge fund tends to do the opposite).
The reason we have one of the cleanest public administrations in the world is because we make them so through our system of controls, regulations, inspections and transparency. But the idea that GPs are somehow special is dangerous, because it lies behind a lot of the policy choices that assume that CCGs don't need to be subject to the sort of governance and accountability safeguards that apply in most of the public sector.
Colin Talbot is a Professor of Government and Public Administration at the University of Manchester, and blogs at www.whitehallwatch.org
