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Aren’t we in a results business?

The annual LMCs conference is a bit like the World Cup – combative, partisan, exhilarating and occasionally ridiculous.

There were the usual corny jokes, stretched metaphors and rabble-rousing speeches, but behind the bluster and camaraderie, delegates knew this was a serious, potentially even momentous, event. General practice is heading for some dramatic changes, and the votes taken by LMCs last week helped lay out the path the profession will take over the next few years.

The key votes were those on commissioning and out-of-hours. The first made clear GPs are firmly opposed to plans either for commissioning to be compulsory or for those who opt out to be financially penalised. The second provided a little more succour for the new Government, with a narrow acceptance that practices should play a ‘central role' in commissioning out-of-hours care, but with the huge caveat that they should not become the ‘providers of last resort'.

GPC chair Dr Laurence Buckman gave what one observer called a ‘militant' speech to the conference – in World Cup terms, he was getting his retaliation in first. Health secretary Andrew Lansley may have started on the right foot, with a series of GP-friendly announcements including the suggestion the patient survey could be scrapped, but Dr Buckman knows the road is about to get bumpier. Sources tell Pulse the Government's white paper on health is due to be released imminently, and it looks set to offer the profession some stark choices on commissioning. There are likely to be generous incentives for those GPs who make a go of it, but stringent financial penalties if they demur.

The GPC is right to decry that approach, and to insist commissioning must be voluntary – and properly supported, resourced and incentivised. If the Department of Health genuinely wants

a positively engaged profession, it makes sense for it to lean more heavily on the carrot than the stick. But the DH is proposing a root-and-branch overhaul of the health economy, with practices to take on virtually all of PCTs' commissioning functions. For such sweeping reforms to work, there must be an equally thorough redrawing of the rules of the NHS.

Secondary care has for too long been allowed to suck up resources from general practice through the ridiculous payment by results system, which pays hospitals not by their results at all, but by their success at inflating their figures. This system also patently fails to hold hospitals to account even for their serial failures, with new figures from the NHS Alliance suggesting discharge data, for example, is getting worse, not better.

Mr Lansley began well last week with his announcement that hospitals will be held responsible for patients who have to be readmitted after premature discharge. But if he is serious about paying the NHS for what it delivers, a more fundamental review is necessary, to get money to where it is really needed. If GPs are to be handed the reins, they must also get the means.

That means a wholesale reform of the way NHS payments are allocated, so money finally arrives where it is most needed – at the primary care front line.