By Richard Hoey
GP commissioning - opportunity or threat? The difficulty general practice has had in answering that question has been the year's big theme, says Pulse editor Richard Hoey
I've worked at Pulse for the best part of seven years now, but I've not known a year quite like the one that is drawing to a close.
It's not been the most dramatic in terms of its contractual developments - 2004 and its out-of-hours opt-out managed that by a fair hand.
Nor has it seen the bloodiest battle between the profession and Government - the 2008 extended hours dispute claims that honour.
But the changes heralded over the last six months by health secretary Andrew Lansley are notable all the same, for being the most divisive among GPs of any I have known.
Normally, it is not so difficult to sense the centre of gravity of general practice. It was plainly obvious from word go that polyclinics and Darzi centres were going to feel GPs' wrath, for duplicating existing services and fragmenting care.
Similarly, while some corners of the profession harboured doubts about the wisdom of handing out-of-hours responsibility to PCTs, those were always heavily outweighed among most GPs by the simple relief at having their lives back.
This time, though, the plans for GP commissioning really have opened up schisms within the profession, setting GP against GP and, increasingly, one GP representative organisation against another.
The big political divisions are not really over whether GP commissioning should happen at all, but about how it should develop, what rules and safeguards should be put in place, and over whether, in the words of RCGP chair Dr Clare Gerada, the plans as they have been laid out represent the end of the NHS as we know it.
Tensions broke out openly before Christmas, with the GPC and the National Association of Primary Care squabbling over whether there should be elections for all key commissioning posts.
The GP negotiators say yes, but the NAPC wants consortia to be allowed to develop within an unfettered market, and argues that if the most competitive model is one run by experienced, business-minded but unelected GPs, then so be it.
That's just one example of friction among many though. The BMA isn't the only organisation to be suspicious of the NAPC's hard-edged, commercial, entrepreneurial approach to GP commissioning.
And I'm told too that tensions are beginning to emerge between the two biggest players of all - the GPC and the RCGP.
GPC chair Dr Laurence Buckman was apparently not overly delighted at the manner with which Dr Gerada declared her intention to lead opposition among GPs to key aspects of Mr Lansley's plans.
Dr Buckman could perhaps have felt that was his job. There may even be a sense - and I'm speculating here - that the BMA felt bounced into the hardening of its stance to the Government's upcoming health bill by the rapturous reception Dr Gerada's comments received among GPs.
Still, so far the various GP organisations have managed largely to keep a lid on the tensions simmering within, and they have done so because the details of how commissioning will work have still not been set out, and so the disagreements of principle have not yet crystalised into real-life disputes.
Expect that to change soon, and don't necessarily expect it to be pretty. The Treasury has joined Oliver Letwin in taking a close look at Mr Lansley's plans, and there's every chance the financial assurances it will seek will prove acceptable to commissioning enthusiasts like the NAPC, but a 'dealbreaker' to the GPC, in the words of one leading member.
And then there's the long-term direction of the plans - the involvement of private companies in supporting GP budget-holding, and the totemic 'any willing provider' policy, which seems on the surface so dull and technocratic, but which encapsulates the different philosophical views about where the health service should go.
One senior figure in the world of general practice recently told me he thought Mr Lansley's plans might be simply a stepping stone to the wholesale replacement of the NHS with a competitive insurance-based system.
If that is right, Dr Gerada's prophesy will have been proved correct. And at that point, it will become impossible to disguise the divisions within general practice.
Richard Hoey, Pulse editor
