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30 pieces of silver

Somewhat improbably, the Jobbing Doctor is a member of one of the country's first pathfinder consortia. But not through choice...

Each day goes by and we are closer to the picture that the Government wants for the NHS.

Each day goes by, and we see the looming death of traditional general practice. Some might think that this is a good thing, but I'm not sure that any of them actually work in primary care. I have contended that Government do not understand general practice and never have. Looking at the way the wind is blowing, they never will.

We have just had the announcement of 52 'pathfinder' consortia. My local area is covered by one, and we had a meeting, which was well attended, at a local hotel, to develop the proposals. I don't know whether it was the weather, but the response from the practices represented seemed pretty lukewarm to me. Calling them 'pathfinders' gives a warm image of travellers bravely walking into the future, with their sturdy walking boots and their compasses, seeking their destination. It is a comforting image, and is designed to give a subliminal image of boldness and vision.

Our pathfinder group is going to be a big one, covering around a third of a million patients. I trust the people who are leading it. Their motives are altruistic. So why am I anxious about what everyone is telling me is a huge opportunity? There are a number of major reasons.

Firstly, this will be set up with so many caveats and conditions that the clinicians will not have a free hand to decide what is best. An example will be the current suggestion that consortia outsource all the back-room functions to India. I cannot believe this is a suggestion that is being taken seriously except by the most blinkered free-market zealots. This follows a suggestion that all appointments for general practice could be managed by a call centre. There will be so many instructions and directions from the centre that there will be little room for manoeuvre.

Secondly, it is an impossible task. We still have quite an efficient health service, when taken as a proportion of GDP. But costs will increase and demand will increase, while the budget will not, and we shall be in a position where the consortia will have to ration care. This will involve painful personal decisions where people will be denied treatments and operations as they are not on the 'list'. This will give media outlets opportunities to run stories like 'Brave cancer mum denied wonder drug' or ‘Living on the wrong side of the road: the postcode lottery' or (even worse) ‘GP commissioners deny operation to teenager'. Just at the time when the role for assessing drugs is taken away from NICE.

Thirdly, it will put us in direct opposition to our colleagues in the secondary sector. They will be unhappy about the role of commissioners, and will make this view clear to the patients, and sometimes will use media outlets to get the point over. Frankly, I wouldn't blame them. It could result in the fragmentation of services in the hospitals. They are far from perfect, but this is not the way I would choose to improve matters. Paranoia is going to be paramount.

There are other ways that I could describe early adopters of the proposed changes. I would not choose to be a pathfinder.

But it seems to me that I am to be a 'pathfinder', after all. There will be modest inducements to be one of the first to embrace the Government's ideas. It used to be called 'The King's Shilling' - others might call it 30 pieces of silver.

The Jobbing Doctor is a general practitioner in a deprived urban area of England.

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