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Are GPs capable of managing an £80bn budget?



Nobody is more qualified to handle the lion’s share of the NHS budget than GPs, says Dr Michael Dixon. But Dr Keith Holton argues that the system is set up in such a way as to make it a poisoned chalice


Of course we are. If we are not, who do we think can do it better?

First, we are used to keeping our own practices within budget. GP practices are, in the main, the most cost-efficient providers in the NHS. At a total annual cost of £120 per patient, general practice offers good value. GPs are experienced in balancing costs across a range of different services while preserving good access for patients.

Whether we have to cope with flu epidemics or increased consultations, we manage to come within budget as the most elastic and adaptable service in the NHS. We know the value of money.

Second, GPs are uniquely placed to decide how other services could be provided more effectively and more cheaply. As clinicians we can challenge some of the more inappropriate and profligate spending decisions that resulted from our current NHS, which is largely driven by secondary care providers.

The third is our trump card. NHS spending is largely predicated on our decisions. NHS expense largely equals the amount that we spend on our practices plus the spending consequences of decisions made when we prescribe, organise a diagnostic test or refer. We’re the people who are largely responsible for how NHS money is spent and so we are logically the only people in the NHS who can cut the NHS cloth to suit its budget.

Of course, we don’t need to manage that £80bn budget ourselves. We’ll employ a host of – hopefully excellent – chief executives and finance directors to do it for us. Nor should we enter this blind. We must ensure that this new responsibility does not threaten either our relationship with patients or our pay as GP providers.

Yet the simple fact remains that we are undoubtedly the best equipped to manage the NHS budget by far and – almost unbelievably – we’re now being asked to do it. This will require only one or two GP leaders in each consortium, working with effective managers. For the average GP it will mean simply being a team player within each local GP-run consortium.

It is not just a question of whether we can do it. We must do it. Or we shall forever continue to complain that secondary care is swallowing up all the resources, that there are too many management consultants and that we never seem to have enough time or resources for our own work in general practice.

The alternative is that we hand this responsibility back to senior managers – disconnected from the working face of primary care – and just accept that general practice will continue as a Cinderella service.

If we turn away from this then we won’t have a leg to stand on if the Government decides to give spending decisions to private consortia, who will then rein us in on every front, from spending, to clinical decisions to our personal income.

Of course, commissioning means great responsibility – that is the price of power. If we walk away from our responsibilities, we will be betraying future GPs. They will become line-managed, low-status, underpaid serfs because their predecessors refused to lead.

Any why would we refuse? Because of… a feeling of inadequacy? Apathy? Fear of the unknown? It is not just a question of whether we are able to commission. It is a question of whether we have the courage.

Dr Michael Dixon is chair of the NHS Alliance and a GP in Cullompton, Devon


In 1974 there was a boy in a school uniform listening to a careers adviser. The man knew medicine was a hard career to get into and took a lot of commitment. He advised the boy to consider accountancy or business management. That boy was me. I wanted to be a GP and see patients and help them. So I said no thanks to business and accountancy.

Like most of us, I imagine, I went into medicine because I was interested in patient care. My training was directed towards this and I don’t recall being taught much at medical school about management or budget-holding.

Along the way I have picked up some knowledge and ideas about running a business – one cannot run a successful practice without having some management skills. But this is small-scale stuff, on a personal level. I know my staff and my partners and we can work together. Even so, we struggle sometimes to reach agreement on what our goals should be and how we should achieve them.

My past experience of trying to work with larger groups of disparate practices in the area is that it is extremely difficult to reach a consensus.

An assumption is being made that all the practices in the consortium will be happy to work together towards common goals, but is this true? Few GPs have the time, inclination, experience or training to perform this sort of role adequately. Some may be enthusiastic as they were for practice-based commissioning – but has PBC delivered value for money? I acknowledge that in some areas PBC has improved services but I see no evidence this is true across the country.

So this is the vision of the future. Managers will be employed by the consortia with administration staff doing the day-to-day back-office work. The enthusiastic GPs can go to meetings – lots of them – to advise on strategy with local forum meetings for other GPs to express their views and be informed. This seems much the same as is happening now but potentially with one important difference. Will it now be the GP who is held responsible if something goes wrong?

While the experienced GP is away at all these meetings, what about the patients? After all, patient surveys regularly show that patients value seeing a trusted, experienced GP and that they value continuity of care over seeing what my US relatives refer to as a ‘doc in a box’.

I think GPs will struggle to achieve any real improvements in most areas because of the way the system is set up.

The primary care sector wants to get the best value, but secondary care – whether NHS or private sector – will want to maximise its income. The market system makes budget-holding a poisoned chalice. Patients have already voiced their concerns. Will I still be the patient’s advocate or more interested in the bottom line?

I am not against change per se. I was involved in fundholding (which I now think was a mistake). I set up and ran an endoscopy unit in primary care and was a LIFT champion.

But GP commissioning seems to me to be an experiment too far. By all means have GP advisers, but let good managers manage and doctors do the job they are trained for.

Did that boy more than 30 years ago want to be a doctor or an accountant? Were his years of training spent to make him a skilled medic or a bean counter? I like to think my answer is still the same now.

Dr Keith Holtom is a GP in Oldbury, West Midlands

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