Is the profession in favour of GP commissioning? We still don’t know

The most fundamental question in medical politics today remains unanswered, writes Pulse deputy editor Steve Nowottny. But it may yet be asked...

Here's the simple question everyone's been asking for the past six months, ever since Andrew Lansley turned the world upside down by unveiling his plans for NHS reform: will GPs go for it?

And here's the answer: astonishingly, we still don't really know.

We know more or less where the GPC stands, of course, which so far could perhaps best be summed up as critically cooperative. We know where the RCGP stands too, which is somewhere quite a lot less cooperative than before Dr Clare Gerada took over as chair.

Other GP representative bodies - the NHS Alliance, the NAPC, the Family Doctor Association - have all also been closely following the plans, and have issued numerous statements on various aspects. But where the balance of opinion among the grassroots members of these various organisations really lies remains less clear.

There have been polls, of course, but these tend to show only, with with a varying degree of authority, what we know already, which is that the profession is split. The BBC, for instance, found that less than a quarter of GPs believe commissioning will improve patient care , while surveys from the likes of the NHS Alliance have painted a very different picture.

Our own polls have been useful in that we've asked the same question twice, which at least allows us to say with some confidence that support for commissioning in the profession dropped off in the months after the white paper was published. But it would brave indeed to pretend that any of these polls offer a definitive answer.

In the absence of hard numbers, wildly optimistic claims have been made on both sides. True believers at the Department of Health have claimed there is an overwhelming appetite among ordinary GPs to embrace commissioning and just get on with it, pointing to the 25% of GPs already included within pathfinder consortia and many more who were part of bids to get started.

Opponents of reform such as those behind the open letter to the BMA last week for their part claim widespread opposition. There are flaws with both arguments: many of those signed up to consortia are far from enthusiastic (our own furiously sceptical Jobbing Doctor, for instance, is theoretically a pathfinder). Equally, there were only a dozen or so GPs among the 119 doctors to sign the open letter to the BMA, which hardly constitutes a mass rebellion.

One part of that open letter did suggest a possible way forward though, for both opponents and supporters of commissioning: 'It is remarkable that despite 'the most radical restructuring of the NHS since its inception', BMA Council recently voted against holding a Special Representative Meeting of the BMA to allow its membership to debate the current proposals. This is in contrast with the BMA's stance against the other most significant NHS white paper reforms, Working for Patients in 1989, when two Special Representative Meetings were called.'

As we report this week, BMA leaders are now under growing pressure to stage that Special Representative Meeting. Despite BMA Council having twice rejected the idea, they are likely to vote on it again at their next meeting on 26 January.

If a Special Representative Meeting was to go ahead, it would effectively be a recall of the Annual Representative Meeting which meets each summer to set BMA policy for the coming year - and would see for the first time the full detail of Andrew Lansley's plans debated among grassroots GPs.

There are compelling arguments against such a Special Representative Meeting, of course. It would be costly, it would take time and it might well fail to deliver a decision one way or the other. It would also - as the BMA were keen to point out this week - only involve already-elected BMA representatives from across the country, so it wouldn't be open to just anyone to turn up and start debating. Besides, the GPC and BMA Council are already grassroots members' elected representatives, and they have certainly been furiously debating the reforms.

There are other alternatives to consider, too. Some kind of ballot, perhaps, although the extended hours negotiations showed that a vote can sometimes leave the profession's true wishes no clearer.

So it may not happen, and if it did, it might not provide a definitive answer. But with consortia already starting to get up and running, and the health bill to go to Parliament next week, the time for asking the question has almost passed.

Steve Nowottny is the deputy editor of Pulse.

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