The Government's behemoth of an NHS bill finally dragged itself across the finish line last month. And all over the country GPs will want to know what it will mean for them.
The immediate answer is that nobody can tell them for certain. As originally described by health secretary Andrew Lansley, the bill was supposed to put GPs in the driving seat when it came to commissioning care. In government, Labour made moves towards GP commissioning models, but that process was always within a planned and managed system. This has an attractive prospect for many GPs. Not only did it potentially mean better care for patients, but there was also the prospect of more autonomy and even cash profits.
Unfortunately, the tortuous process of the bill and the innumerable side deals that Lansley had to cut to get it through means that, instead of eliminating bureaucracy, the new bill will create even more.
PCTs will be eliminated. But in many parts of the country they have already been replaced by shadow commissioning groups. And on top of them, we are going to see clinical senates, health and wellbeing boards and other layers of bureaucracy.
Neither is it clear exactly what all these new entities will do. Lansley's original vision at least had the virtue of relative clarity. The bill that has emerged is an incoherent mess.
While PCTs will not be mourned by most of the general public, folding them up potentially means expertise and institutional memory will be scattered to the wind. What is certainly happening is that experienced PCT staff members are taking their redundancy.
But many will have to be re-employed, at even greater expense. No wonder the cost of this reorganisation is estimated at £3bn and rising.
Many GPs will welcome being empowered to purchase care. It has been tried before. Remember fundholding and practice-based commissioning? Yet what we know is that many GPs will not want to get involved in commissioning.
Some will be only too happy to commission off the shelf from the private sector. And quality premiums will be awarded to GPs who ration care.
Dr Laurence Buckman, chair of the GPC, has called this ‘disgracefully unethical'. And Dr Clare Gerada, chair of the RCGP, has said GPs will ‘have to choose between the best interests of our patients and those of the commissioning group's purse'.
Pulse recently reported that a GP surgery in West Sussex had written to all its patients offering them ‘private screening for heart and stroke risk' from Health Screen First – a private company – and in return the surgery receives ‘a nominal fee from Health Screen First'. Last year a GP practice in York sent a letter to patients with the charges shown for certain treatments that are currently free on the NHS.
Buying in care
This brings us to the aspect of the bill that Lansley was never too anxious to talk about. The bill brings the private sector into the heart of the NHS.
Labour (controversially) used independent-sector treatment centres to bring down waiting lists. But this new regime will not only see a sharp rise in the use of private-sector hospitals; the private sector will increasingly be used to purchase primary care and hospitals will have the cap lifted from the proportion of private patients they can treat, up to 49%. Historically, a handful of hospitals like the Royal Marsden in London have been allowed relatively high numbers of private patients.
But the vast majority have had percentages of private patients in single figures. With the cap lifted and hospitals under unprecedented financial pressure, you can expect the numbers of private patients to rise steadily.
Rather than giving more powers to local GPs to decide when and where to use managed competition, the health bill will force commissioners to use competitive tendering even when local clinicians, health and wellbeing boards and the public do not agree. Some aspects of public health will now be purchased by local authority directors of public health. Other aspects will be purchased by clinical commissioning groups. But it is still not clear exactly where the dividing line will be.
This Government thinks passing the health bill is the end of its problems – but it is just the beginning. In his anxiety to open the NHS up to the private sector, Andrew Lansley has created a potentially fatally fractured service, which may tragically undermine the bond of trust between doctors and patients.
Diane Abbott is the MP for Hackney North and Stoke Newington and shadow public health minister