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Who would want to be a GP commissioner now?

Liberal Democrats, Tory backbenchers and the NHS Future Forum have all had their say, and what GPs are left with is a muddled mess, says Pulse editor Richard Hoey

OK, let's start by acknowledging that the Government has had one hell of a job on its hands. It's not been an easy task to salvage its NHS reforms.

Our health secretary, as some have rather cheekily been referring to Prime Minister David Cameron, has somehow had to balance the wildly competing interests of the Liberal Democrats, his own backbenchers, the BMA and the various worthies on the NHS Future Forum.

With that many cooks, it's a wonder Mr Cameron was able to whip up a new version of the health bill at all, but even the PM's considerable political skills couldn't avoid the new plans being a muddled mess.

First the good stuff. This was a health bill badly in need of modifying, and some of the changes announced today do indeed take the hard edges off the reforms, just as GPs have demanded.

The softened deadline was necessary, although the way it has been framed, with many consortia still expected to take over in April 2013, but others potentially able to avoid ever taking over budgetary responsibility, leaves the way open to a two-tier NHS.

Monitor has had its over-arching role in promoting competition sensibly diluted and any willing provider will not be universally implemented (although GP commissioners still don't get any say over when it is appropriate to use it).

And it is right, given the persistent concerns over conflict of interest, that consortia – or rather, clinical commissioning groups - will have to be fully transparent in their decision making, including having lay members and publishing all their minutes.

Others of the changes proposed have been made in response to genuine and justifiable concerns, or strongly held political beliefs – hence the beefed up roles for hospital consultants and nurses, and the tough scrutinising role to be played by local authorities, via their health and wellbeing boards.

In fact, a case can be made on an individual basis for a great many of the changes to be implemented. It's just that taken together, they are fiendishly complicated, alarmingly bureaucratic, and look self-evidently expensive.

They raise a couple of key questions, the first of which is - if we were to design a set of NHS reforms from scratch, would anyone come up with something that looks like this?

Yes, GPs retain their role as lead commissioners, and indeed look like retaining their distinctly unwelcome financial responsibility for commissioning via the hugely controversial quality premium.

But while GPs get the responsibility, it is extremely unclear that they will get any real power. Clinical commissioning groups will be overseen by a proliferation of different organisations – by the NHS Commissioning Board and its regional branches, new clinical senates, Monitor, health and wellbeing boards, groups of public health doctors where appropriate and for at least the next couple of years SHAs or clusters of them.

Take those clinical senates. As proposed by the NHS Future Forum, these were advisory bodies set up to provide each consortium with specialist advice where appropriate – but they have somehow transmuted into another exercise in managerial control.

Senates will sit as part of the increasingly all-powerful NHS Commissioning Board, providing advice GP commissioners will be ‘expected to follow', with a ‘formal role in authorisation' - or, as such advice is more commonly known, instructions.

And then on top of that, and against the advice of the Future Forum, a consultant and a nurse will get places on the boards of clinical commissioning groups (although unlike GPs, they presumably won't get their pay docked if the budget busts).

The Government has attempted to neatly sidestep concerns over conflict of interest by insisting the consultant and the nurse can't work for local providers, although just how a commissioning group in a rural area is supposed to manage that, without drafting in someone from miles away, is not clear.

But sourcing the extra board members is the least of the worries for some GP commissioners.

Commissioning groups will now, unless they can come up with a very good reason, be expected to share borders with local authorities, which would have made absolute sense at the outset of the reforms, but is now likely to require some seriously problematic reorganisations.

At least local authorities, unlike senates, won't actually be able to tell commissioning groups what to do – but they will have to be consulted on all key decisions, and if they don't like the outcome they have the right to appeal to the big boys at the NHS Commissioning Board.

And that is the fundamental problem with these reforms. Everywhere there are instances where GP commissioners are not being trusted to commission, where new controls are being laid down, new bureaucracy embedded to mitigate the risk.

They are in many ways an understandable and in some cases a sensible reaction to health secretary Andrew Lansley's dangerously vague and overly radical original plan.

But it is worth asking the second key question – is there anything in this version of the reforms that couldn't have been achieved by beefing up GP commissioning sub-committees, and increasing democratic accountability, within existing PCTs?

Richard Hoey, Pulse editor

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