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Entering the ring with consultants

Our diarist finds himself having to answer to local consultants on the reforms.

The story so far

Dr Peter Weaving is a GP and locality lead in Cumbria, now deemed a cutting-edge pathfinder consortium in light of its commissioning successes – not least in steering the PCT out of a £50m deficit. An unashamed enthusiast for the reforms, he is nevertheless conscious that competition has less of a ‘bite' in rural areas than in other parts of the country – and that not everyone in Cumbria shares his vision

Serried ranks of consultants look down on me from their seats in the lecture theatre of our local trust's postgraduate centre.

A meeting of all consultants and GPs has been called by the chair of the consultant's committee following ‘an inflammatory article' in The Times. Said article quotes me as saying all is rosy in the garden of GP commissioning in Cumbria. Clearly it is not for this trust which has decided, quite rightly, not to seek foundation trust status on its own but to merge with an existing FT to form a new organisation. As the lecture theatre fills, I try to read the expressions of my consultant and some GP colleagues – many of whom I have known and worked with for over 20 years. I sense mainly anticipation, as before a good sporting event. Let's hope it's badminton, not boxing.

It is a strange time – PCTs have been given their marching orders, hospital trusts have to prove their financial independence or go down the merger/acquisition route with no middle ground. GP consortia are the new commissioners or managers, so if things are going wrong it must be their fault.

First into the ring is the senior orthopaedic consultant who lets fly with a volley of financial slides, and with some deft footwork delivers some body blows – including £71m private spend and per capita funding half of what it is for other trusts in the county. The trust is carrying out more operations, but being paid less for them.

I respond feebly with a Grade 5 Maths O-level and a history lesson. The reality is we have never quite made it financially as a health economy – even before the internal market we always received winter pressures money, an inefficiency incentive paid to trusts that ran out of money three-quarters of the way through the year. This belief that something will always turn up has persisted and it is not the fault of management or consultants or commissioners, GP or otherwise. It is the fault of all us together.

The reality is that Cumbria has the capitated funding for one big hospital in the middle of the county, but the inconvenient truth of the Lake District means we need three or four scattered round the edge – so we have to be more efficient than other areas. There are no subsidies for multi-site working, expensive PFI buildings and rurality in the new world. If 20% of patients choose hospitals outside the county, that is a loss to the local economy and will hammer down the per capita income for the local hospital. We need to raise the profile and range of services to repatriate patients locally for both routine and, more importantly, specialised services.

The conclusion of the bout for me is that the challenges ahead are not going to be solved in an adversarial or contractual way – we are not going to count our way out of trouble. The solution lies in real clinical partnership with primary and secondary care delivering a joined-up service together.

Dr Peter Weaving