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Too much of a good thing

The new Government's plans for commissioning offer GPs a stark choice.

Cliches are often cliches for a reason, in that they tend to contain more than a grain of truth. It really is possible, for instance, to have too much of a good thing. Take the new Government's plans for GP commissioning. According to highly placed sources, practices could be asked to take control of as much as 95% of PCT budgets.

Even some GPs who have thrown themselves enthusiastically at practice-based commissioning may balk at that figure.

Practices do already play a far larger role than is often appreciated in distributing NHS funding, paying out for nurses, pharmacists, counsellors and a dizzying array of clinical services. The new plans, though, are something else besides, with practice groupings set to almost entirely supplant the role of PCTs in routinely commissioning not just primary care but a full range of acute services.

Many GPs will welcome the opportunity to become more actively involved in the planning of the local health economy, particularly if it means a veto on misguided plans for Darzi centres or an excessive shift of care into the community. But there are real questions over the feasibility of the Government's current proposals, and over the levers it intends to use to ensure they become reality.

The health bill outlined last week would not only see the role of PCTs shrink away, but would eventually scrap SHAs entirely, their places taken by regional offices of the new national NHS Board. Few GPs will mourn SHAs, which have thrown their weight around on behalf of the Department of Health with all the subtlety of night club bouncers. But with both PCTs and SHAs effectively off the scene, the plans leave

a gaping chasm between the national board and local GP groupings. GPs really will need to make a go of commissioning because if they don't, there is a serious risk that health planning could be sucked upwards to the national board, making the whole process more, not less, centralised.

Health secretary Andrew Lansley must be acutely aware of that danger, and of the failure of commissioning initiatives so far to engage GPs. All the signs are that he is planning a dramatic shake-up of the GP contract to make sure practices really do take their commissioning role seriously. And it may not be pretty.

Pulse's sources suggest the DH wants a new GP contract held centrally by the NHS board, which will have an ominously powerful remit to manage practice performance.

It doesn't look like commissioning will be compulsory, but GPs are set to be offered a stark choice – either to accept it as a key part of their job, or to settle for much lower income.

These plans are incredibly ambitious and may deliver exciting improvements in patient care. But they also threaten to create a two-tier profession, in which GPs who feel their job is to deliver high-quality care at ground level are sidelined and underfunded. Commissioning is a vitally important GP skill. But there is a danger it will become the only skill valued by the NHS.