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A few things that keep me awake at night – and it’s not governance

Our editor gets some concerns off her chest.

Turning 40 this year, where to go for summer hols, did I remember to let the dog out…...Sorry, nearly dozed off there.

I went to a training event the other day where I was asked to speak to a few charities about the reforms. I entered the room as the speaker before me was signing off with ‘do come to the demo tonight, we all need to do our bit to protect the NHS..'

As I rattled through my slides showing some innovative case studies we'd featured in Practical Commissioning I started to become aware that compared to my predecessor I was beginning to sound like Tory girl.

Practical Commissioning has made its mark by showcasing what GP commissioning can do and featuring the successful and the innovative. As I spoke I realised I'd got very used to the idea GP commissioning can work. I speak to GPs all the time who take it as a given and it's rubbed off on me. So to counter this effect I thought I'd share my concerns about the reforms.

1. Managing demand. The Co-operation and Competition Panel's interim report on any willing provider worries me. If its final report in June does not allow consortia to manage demand through traditional – albeit ‘anti-competitive – means such as vetting referrals, setting thresholds, there will be a free-for-all among patients demanding operations. Budgets will go out the window and GPs will walk away from commissioning.

2. Profit margins. Everyone seems to have picked up on price competition in the bill which the Government has now reneged on, but how are we going to stop big companies making big profits?. Yes, all providers are going to get paid the same price now, but what will stop one company setting a profit margin at 45 per cent as long as it ticks the quality boxes and delivers. To me, this is the biggest issue if we are to learn anything from the rail and prison services. It's just wrong for companies to make big money out of services we taxpayers pay for. We need to find a way to emulate what these big companies do and plough the surplus they are able to create back into the NHS. Instead, the pro-NHS campaigners seem to be having a baby about a GPSI doing some minor op work that will just about pay for their skiing holiday that year. Come on people, look at the big picture here.

3. How consortia will make decisions. I went to an event the other day organised by the University of East Anglia which provides support to PCTs on how to make effective commissioning decisions and priority setting methods. Taking commissioning decision making away from managers and transferring it to GPs makes absolute sense but on what basis are GPs going to actually make commissioning decisions? It all seems to be sense and feel. Yes, you can use data to gauge patient need but what are you commissioning to achieve? Keep patients out of hospital? Spend X amount to achieve X QALY? Keep as many patients as poss healthy or ensure the most ill have the best care? Or will it just come down to numbers – we need to make £4 million ‘efficiency savings' this year. Hardly transforming the NHS if the latter proves to be the driving force.

4. Same old enthusiasts. When the white paper came out last year all GPs were talking about commissioning. A few weeks later and one grassroots GP said to me ‘I'm bored of commissioning now'. I do sense we are seeing the same old faces in this brave new era – at the RCGP, at the NHS Alliance, on the latest listening forum. There seem to be about 20 GPs who pop up time and again. I sense many lay GPs are just assuming their commissioning enthusiast colleague will simply take care of it for their practice while they can remain in their consulting room silo. Will that be enough to maintain a NHS that's free at the point of use?

Time for some valerian tea me thinks.


Sue McNulty - looking sleepy?