By Richard Hoey
Revisions to the health bill are desperately needed, but with so many different players, there is a risk GPs will be left with a messy hotchpotch, says Pulse editor Richard Hoey
Andrew Lansley's dramatic reforms of the GP role have run the full gamut from exciting to scary to – ever since the now near-legendary ‘pause' – rather humorous.
That was certainly the sense at the BMJ Group Awards I attended earlier this week, where many of the doctors who took to the podium seemed to find it impossible to resist slipping in some light-hearted dig about the reforms.
Perhaps the only person who isn't laughing is the health secretary himself, who has found himself in the unpleasant position of being pulled and pushed from almost every angle, like a flag being tugged at each corner.
In one corner are the Lib Dems, who emboldened by the spring conference vote, and infused with a nothing-more-to-lose gung-ho spirit since the May elections, are falling over each other to toughen up their demands for changes to the bill.
First Nick Clegg suggested GPs might not be forced to take on commissioning, and then he disparaged the Conservatives' enthusiasm for the private sector and insisted Monitor's role should be about promoting integrated care, not ramping up competition.
Dr Evan Harris, vice chair of the Lib Dems' federal policy committee and self-styled voice of the party's centre-left conscience, went even further, insisting every element of the spring conference motion would need to be enacted, including having councillors on GP consortium boards.
In another corner is Prime Minister David Cameron, who may still in theory support the reforms, but doesn't want it to look as though the Tories were forced into change by the Lib Dems, and so is keen to grab some glory for modifying the bill for himself.
Mr Cameron this week acknowledged there would need to be a much stronger role in commissioning for hospital doctors, which felt like a substantial bone thrown to the BMA, who stand in one corner beating the drum for an integrated NHS.
Finally, there is the Tory Right, who have rushed to Mr Lansley's defence and insisted that attempts to water down competition – and allow NHS consultants to sit on consortium boards - would destroy a core element of the legislation.
So where does all this leave us? Well, in a pretty complicated place. I'd defy anyone to come out and predict with any confidence what kind of bill we'll end up with, and quite what the role of GPs will be within it.
There are a few changes that look almost certain to be enacted. There are bound to be tougher governance checks on consortia before they are allowed to take on commissioning, which presumably also means some extension of the handover deadline, at the very least for those who don't comply.
I suspect too that there could be clearer requirements on consortia to be fully transparent in their decisions – that's something the Lib Dems want which doesn't feel like it would put Mr Lansley's nose out of joint too badly.
After that it gets quite a bit trickier. I wouldn't be surprised to see councillors get a toughened up role in working with consortia, which might include a representative or two on consortium boards.
But hospital doctors? Having representatives of NHS providers on boards is complete anathema to Mr Lansley's original proposals, and from what I hear he's fighting this one hard. I suspect they may get a formal role that stops short of being a board position, all assuming that Mr Lansley stays in post.
And then there's competition, Monitor and any willing provider. I think the Tories will have to compromise a bit here, perhaps by making clear that European competition law will not apply to the NHS.
But I'd guess any willing provider will stay. I had wondered whether the bill might be modified to allow consortia the discretion to use any willing provider or not – something the Commons health committee recommended – but I'm told that hasn't even been raised in the listening exercise.
And actually, I see that as symptomatic of a wider problem. The NHS reforms have become so swept up in political grandstanding and big-picture rows that there is a real danger some of the key details – which also include whether GPs will be rewarded for rationing healthcare to stay within budget – may get lost.
There's a risk what we end up with will be a hotchpotch mess of different ambitions and political ideologies that will leave GPs even more confused than they are now.
In which case, Mr Lansley's pause may lose its capacity to amuse.
Richard Hoey, Pulse editor