There is widespread fear that current proposals will not work and, among some, that they represent a secret plot to privatise the NHS. These fears are founded upon ten main arguments that require detailed examination:
1. Things are OK as they are.
This line of argument cites the Commonwealth Fund showing that we are one of the most cost effective and equitable health services among developing countries and points out that waiting times and services are generally pretty good. But are they?
The next few years will see a different financial picture and inevitable worsening of all services unless we can get ‘more for less’. That means more elderly and multi-morbid patients being looked after in the community rather than hospital. It means enabling patients to better self care, improving personal and community health and de-professionalising care where appropriate. Our current system has failed to touch any of this for a multitude of reasons but there is a real possibility that clinical commissioning and health and wellbeing boards might make the necessary difference.
Yes, the NHS is good but it is certainly not integrated at present. Nor is it affordable as it stands and as the storm clouds of future financial stringency begin to gather. It may be fair in comparison to other health systems but it is failing to prevent widening inequalities. In short, along with most western health systems, it is not currently fit for the future.
2. Clinical commissioning will threaten the relationship between GP and patient and the GP advocacy role.
The argument here is that we cannot be both individual patient advocate and at the same time responsible for rationing, prioritisation and best use of NHS resources generally. This argument does not wash partly because, in effect, we already are and always have been rationers or gatekeepers of care. Indeed it is one of our important functions and considerable success story.
In the new world, our role may change a little as we try to balance the good of the individual with the good of the greatest number. It is a dichotomy that is in a way as noble as it is inevitable if, as clinicians, we really do believe in a sustainable NHS. Clinical commissioning is thus a moral duty as well as a practical necessity. In many ways, it seems odd that this was not enshrined in our contract, when the NHS was introduced in 1948.
3. Clinical commissioning leads to conflicts of interest that will undermine patient trust.
This is argued on two levels. The first is that if GPs are incentivised to reduce use of NHS resources then patients might justifiably claim that a GP could be withholding referral as a means of gaining personal financial advantage. This was a case that could have been justifiably argued under GP fundholding, which attracted over 50% of GPs. Consequently CCGs and GP practices will need to be very careful about how they organise any commissioning incentive.
The second potential conflict of interest between is between the GP as provider, possible provider of a number of services currently provided by hospital community services and the GP as commissioner in an advantageous position to commission such services. A solution to this dilemma is simply for there to be a glass ceiling between the GP role as commissioner and provider, which will involve transparency in all commissioning decisions along with declaration of interest by those making commissioning decisions. The corporate governance of CCGs, involving local people, need to take account of this. While these conflicts can be overcome, it is clearly important that GPs and practices are remunerated for time involved in commissioning and that more services are moved into general practice and primary care, where clinically and economically appropriate.
4. ‘GPs do not have the time, skills or experience to commission.’
It is not, perhaps, surprising that non GPs should be saying this. It is disappointing, however, to hear some fellow GPs reiterating the same concerns. Undoubtedly an MBA is useful but it is certainly not necessary to commission successfully. All GPs are already commissioners in as much as they need to make decisions about referrals, diagnostics and prescribing. Commissioning simply puts them on a bigger stage. As clinicians with a wide clinical perspective and small businessmen, we are best placed to lead commissioning decisions.
That does not mean that we won’t need advice from specialists and other clinical colleagues nor does it mean that we have to get involved in the details of administration, finance and contracting for which we will need experienced managers. What we are talking about is time and expertise from a few clinical commissioning leaders – who are already coming forward to do the job – and the level of involvement and ownership by the rest of us, which need not hamper our clinical work but will contribute to us working within sustainable resources. As GPs, we should, perhaps, have greater confidence in our abilities and in those GPs, who are keen to lead the process.
5. ‘Clinical commissioning groups are being set up so that GPs will be blamed for resources shortages especially when, inevitably, they go bankrupt.’
It would be odd of Government to design a system that was meant to fail and which could insulate it from such failure (see 9). It is true that CCGs are being set up at a time of financial austerity and that their need might not have been equally recognised if financial times had been better. Clinical commissioning groups, however, will not be the rationers. It will be Government that sets the financial limits overall. CCGs can only do their best within such limits and not be apologists for NHS underfunding, should it occur.
If anything, the new collective voice of frontline clinicians and commissioners could provide a previously unheard of head of steam that would enable clinical commissioners to hold the centre and Government to task if budgets did become too tight. If and where some individual CCGs do go bankrupt, then their management is likely to be taken up by a neighbouring CCG temporarily or permanently, which will hardly affect individual clinician/patient relationships.
6. ‘The reforms put competition before patients and will lead to a poorly integrated and fragmented NHS.’
The reforms do encourage greater competition in a similar vain to the reforms introduced by Tony Blair and Alan Milburn. As a GP, in the 1980’s, competition between practices was more overt and if a neighbouring practice opened on Saturday mornings or offered more nursing services, for instance, neighbouring practices followed suit rapidly. As a commissioner in the 1990’s, the only means of reducing local orthopaedic waiting times was by threatening to put our hospital orthopaedic contracts elsewhere. It took only two months to reduce waiting times for an acute knee from 18 months to 2-4 weeks. Competition may not be entirely welcomed by those being asked to compete, which may be the source of some NHS voices against competition, but it can be good for patients and services.
7. ‘Clinicians and Clinical commissioning group leaders are fooling themselves that they will be given real power to change things. The idea is simply to devolve responsibility for NHS failure.’
Of all the ten issues mentioned, this is the one that is of most concern to clinical commissioners. Many have been out to bat several times before – as GP Fundholders, Locality commissioners, PCGs and latterly as Practice based Commissioners. They have seen it all happen before. The Government’s point, however, is that this is a serious attempt to empower clinical commissioners by giving them statutory responsibility and they have accepted considerable flack for doing so. CCGs are faced with two main threats to their independence. The first is the National Commissioning Board and inevitable fears that it will create the same sort of hierarchies that have managed to neutralise any previous attempts at decentralisation and have thwarted clinical leaders with a primary care focus. The other fear has been the issue of markets and competition wrong footing the decisions of CCGs (see 6).
8. ‘The intention behind the Bill is to privatise the NHS and leave us with something looking like the US system.’
It’s possible to argue, as the last Government did, that the essence of the NHS is kept provided that commissioning is in ‘publicly accountable hands’. Privatisation of commissioning is something that no one would want to see. Some have argued that the use of private providers for commissioning support could lead to this very scenario as clinical commissioners become dependent on these private providers for their commissioning and the servant effectively becomes master. The perceived ‘imposition’ of private provider support offered/foisted on some CCGs has added to this impression. Indeed, it has been argued by BMA/RCGP that clinical commissioning groups should be very large indeed so that they can afford to organise most of their commissioning in house so as to avoid the need for private commissioning providers.
9. ‘The Bill will allow the Secretary of State and Politicians off the hook, when the NHS fails.’
The idea of separating politicians from the NHS, like the concept of CCGs themselves, originated with frontline clinicians. The proposal, similar to separation of the Bank of England from Government, was supported in papers from NHS Confederation and the King’s Fund. Preventing day to day interference by politicians does not absolve them from all responsibility. Current changes to legislation in the Lords will return much responsibility to the Secretary of State. Anyway, whatever is said in law, neither the Secretary of State nor a Prime Minister will survive politically if the NHS goes down.
10. ‘There was no need for these huge changes. The system would naturally have evolved to achieve what clinical commissioning groups are aimed to achieve.’
The only answer to the hypothesis that there is no need for change and that we can blithely continue is a resounding… ‘There is a hole in my bucket!’
The NHS is not perfect. It is facing new problems that the old system has failed to sort and, persistently, the old system has rejected and disempowered the concept of clinical commissioning. Perhaps the reforms could have been less disrupted and perhaps some parts of the Bill are unnecessary but the fact remains that without a jolt of some sort, our NHS will become mediocre and financially unsustainable.
But iIf GPs are unprepared to take on a role as commissioners then either the Government will look for someone else to do the job (? private commissioners) or will abandon commissioning altogether and general practice and the wider NHS to the hounds of private industry and our worst fears will come true.
The reforms are not a Government plot to disgrace clinicians or to privatise the NHS. They are being brought in by a Government that believes in the potential of frontline clinicians and which has historically favoured markets and competition.
Most clinicians, particularly GPs, are pragmatists. So, in a way, the only way is forward and now is the time for frontline clinicians to embrace change rather than be flattened as it inevitably proceeds.
Dr Michael Dixon is a GP in Cullompton, Devon, and chair of NHS Alliance