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GP quality premium opens new divisive front on health bill

By Gareth Iacobucci

Exclusive: Controversial plans to pay GPs according to their ability to control commissioning budgets have emerged as a key battleground on the Government's NHS reforms, as its listening exercise draws to a close with huge divisions remaining between the main players.

Professor Steve Field, chair of the NHS Future Forum, warned consultation respondents were acutely divided over proposals for a 'quality premium' to reward consortia that hit clinical and financial targets, as he took final submissions this week.

GP consortium chairs and LMC leaders claimed the NHS was being crippled by a policy 'vacuum' and that further delays to the health bill would be a 'disaster', after Liberal Democrats indicated it could face months of scrutiny from MPs.

Deputy prime minister Nick Clegg revealed last week the bill was likely to be significantly delayed while it was recommitted to Parliament, and that the 2013 deadline for all GP consortia to take over budgets was set to be pushed back.

But GP consortia and PCTs have been left unable even to plan for delay, with sources close to health secretary Andrew Lansley furiously counter-briefing that speculation the bill would be put back six months was 'wide of the mark'.

Professor Field told Pulse that along with well-publicised debate over NHS competition and whether hospital consultants should join GPs on consortium boards, the listening exercise had also revealed a sharp divide over the quality premium: 'We've heard a variety of views. There's a view if it was just used to reduce referrals and reinvest the money there could be real conflicts of interest. Others say it could be used as an incentive to improve quality.'

In a joint letter to the Prime Minister last week, the National Association of Primary Care and NHS Alliance praised plans to align clinical and financial accountability, insisting they would 'mean the opportunity cost of commissioning decisions will become a real consideration for frontline clinicians'.

But the BMA's response to the forum, published last week, demanded quality premiums were removed completely from the bill, and new guidance published today expresses serious concerns about instances where GPs' decisions regarding the care of their patients could influence 'completely unethical' financial incentive schemes.

RCGP chair Dr Clare Gerada also criticised plans for a quality premium last week, describing them as risking 'perverse incentives' for GPs, while delivering her most positive verdict yet on the principle of GP commissioning. ‘Our worry is we shouldn't throw out the baby with the bathwater,' she said.

The conclusion of the listening exercise comes as a Pulse survey of 20 pathfinder consortium leads found 40% felt their momentum had already stalled, with many warning QIPP was being derailed as a result.

Dr Peter Melton, shadow accountable officer of the North East Lincolnshire consortium, said: 'If you break down the £20bn that needs to be saved over four years, that's £400m a month – so delaying implementation for a couple of months will cost about £800m.'

PCT leaders described the 'utter shambles' of trying to plan budgets without any idea even of when they would cease to exist, while LMC leaders said the current state of flux was causing huge instability.

Dr Nigel Watson, chair of the GPC's commissioning and service development subcommittee and chief executive of Wessex LMCs, said: 'In some areas, it's the worst of both worlds. No one is making decisions. We need clarity as soon as possible. If they completely throw it out, it would be a disaster.'

Dr Michelle Drage, chief executive of Londonwide LMCs, said: 'The longer we stay in this strangulated pause, the more uncertainty there is.'

Key battlegrounds

Will the Government row back on plans to make Monitor's primary role a promoter of competition, following the surge of criticism from the BMA, RCGP, Labour and the Lib Dems?

Hospital doctors
Should space be reserved on commissioning boards for hospital doctors, as demanded by the Royal College of Physicians and others, or would their presence be tokenistic and create too many conflicts of interest?

Quality premiums
Will the Government push through plans to link GPs' income to their commissioning performance, and if so, what proportion will it opt for? Or will it heed the BMA's warning and shelve the plans?

Professor Steve Field