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So much for the calm before the storm

It is alarming that stories of cutbacks and under-provision from GPs are already surfacing.

This is supposed to be the calm before the storm. The NHS has to make £20bn in efficiency savings by 2014/15, but the real budget hacking has yet to begin.

Primary care organisations did, after all, get a relatively healthy uplift of 5.5% for the current financial year. So it’s alarming how the stories are mounting up of cutbacks and under-provision, with complaints from GPs that they are unable to implement even quite basic elements of NICE guidance.

Last week, we reported that PCOs were failing to fund the institute’s guidance on back pain, and that some were turning down all requests for IVF. This week, we learn some are tightening their criteria for hip and knee replacements, refusing access to tonsillectomy and cancelling counselling services. If this is the calm, GPs had better brace themselves for some pretty nasty weather ahead.

It’s extremely frustrating that PCOs are rushing into such brutal cutbacks before the budget squeeze has truly begun to pinch, and suggests flaws both in their funding model and spending decisions. After a decade of record budget increases, PCOs really should be able to fund treatments NICE says patients have a right to receive, particularly since that right is now enshrined in the NHS Constitution.

But PCOs are not cutting for fun. Indeed Pulse this week reveals many are panicking that they are not cutting quickly enough, with mid-year projections suggesting they are heading to bust budgets or miss efficiency targets. The likely outcomes are grim. PCOs may cut faster and deeper, shrugging off concerns over access to treatments and perhaps ignoring the new requirement, at least in England, to consult with GPs. Or they may shirk the budgetary challenge, in the knowledge they won’t be around to carry the can. If that happens, GPs will face a mountain of debt when they take over commissioning – debt the GPC concedes is likely to become the profession’s problem.

But it will not only be debt that becomes GPs’ problem. So will the legal duty to provide NICE-approved treatments, with consortia risking being sued if they fall short. As NICE green-lights more and more treatments, without worrying about anything as inconvenient as a budget, so the pressures on GPs will increase.

There is no simple solution, but there is a need to ensure the legacy passed to GPs is as benign as possible. Trusts need to consult GPs now, not just on large-scale reconfigurations, but about everyday funding priorities, with a remit to halt wasteful services such as Darzi centres. NICE, too, should reform, by making recommendations within a notional annual budget, so GPs are not left with all the tough financial calls. Otherwise, the cynics on GP commissioning could be proved right – that it is just a way to shift blame for rationing onto GPs’ shoulders.

Pulse editorial