Professor John Fabre, professor of clinical sciences at King's College London School of Medicine and an honorary consultant at King's College Hospital, discusses some of the wider implications of the Government's white paper reforms
The cornerstone of the Government's proposed reforms is to place GPs at the financial and organisational centre of the NHS. It envisages that the financial independence given to GPs will improve their services, that their purchasing power will provide indirect pressure for improvement of the hospital service, and that GPs will act as the rationing point for capping expenditure.
Commissioning services
GPs need access to high quality local support services, such as district nursing, physiotherapy, hospices, nursing homes etc. Devolving the commissioning of these local services to GP consortia makes excellent sense. Devolving the commissioning of hospital services to GP consortia, however, makes no sense whatsoever. GPs need access to a high quality hospital service. The provision of the hospital service should involve management structures entirely distinct from those governing general practice.
General practice
Without a strong general practice base, the Government's plans, whatever is finally agreed, will be compromised. However, the Government ignores the fact that the organisational structure of general practice is deteriorating.
There is now a major financial incentive - and there are few practical problems - with reducing the number of GP partners in a practice. This has caused a distinctly two-tier system of GPs: partners on one hand, and on the other, an increasing cohort of less well-paid and often-disgruntled salaried and locum doctors (now 40% of GPs). Job opportunities for young doctors have diminished, and general practice is becoming a less popular career choice. This can be remedied by restructuring practice incomes to include substantial financial incentives to employ partners rather than salaried doctors.
Reintroducing the contractual obligation for out-of-hours care is also important, probably by way of GP cooperatives. Cooperatives provided an excellent service for patients, and gave GPs the freedom of doing a greater or lesser degree of out-of-hours work. Most importantly, the clinical risks involved with foreign GPs, and the costs of vetting such GPs, would automatically disappear.
Premises are, legally speaking, the responsibility of GPs. However, it is usually left to PCTs, who engage private companies to build and maintain premises in exchange for a guaranteed (usually high) rent from the NHS. All GPs should take responsibility for their premises, with the NHS monitoring quality (without setting absurdly luxurious standards) and paying a modest rental, most simply based on a capitation fee.
Promoting excellence in general practice
A great deal of the pressure for improving the quality of GP services in the current NHS comes from financial incentives to meet specific targets. In many cases this has been highly effective, but it requires substantial administration. Sometimes the targets have been motivated more by politics than clinical need. Is there a simpler approach?
At the moment, patients have little knowledge of what to expect from their GPs, eg if they are diabetic or hypertensive, how frequently should they be reviewed? The Department of Health should, together with GPs' representatives from the BMA and the RCGP, draw up broad guidelines as to the service patients should expect. These guidelines should be made available to all patients, who can then gauge for themselves the quality of their practice, and change practices if they feel the quality falls short.
This system will be effective only if the greater part of GPs' income is derived from a capitation fee set at a higher level than at present, so that practice income bears a strong relationship to the number of patients on the list. Market forces driven by patients' expectations, and the capacity of practices to deliver those expectations, could be an important factor in maintaining and improving standards.
The hospital service
A central component of the Government's reforms is to put doctors in charge of the GP service. However, it is silent about the hospital service. The Government should be equally strident about putting doctors and nurses back in charge of the hospital service. The post of chief executive in the NHS seems to attract the wrong sort of people.
Unless the management of hospitals is greatly improved, they will not be able to respond effectively to pressures for improvement.
Professor John Fabre is professor of clinical sciences at King's College London School of Medicine and an honorary consultant at King's College Hospital.
Professor John Fabre: GPs should not commission hospital services Professor John Fabre: GPs should not commission hospital services
