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GPC is fighting the unwinnable war over the UK-wide contract

By Richard Hoey

Negotiators are contorting themselves into some awkward positions over their desire to keep commisioning out of the contract for English GPs, and risk making some damaging concessions elsewhere, says Pulse editor By Richard Hoey

It's a fundamental principle of negotiation.

Pick your battles. Assess how you match up to your opponent and which offer the best prospect of victory. Be prepared to concede ground where you can afford to lose, but fight like mad when you know you need to win.

It's interesting to assess how the GPC is matching up against that principle, as it enters talks with the Department of Health over GP commissioning.

GPC chair Dr Laurence Buckman sets out his negotiating stall in some detail in this week's interview with Pulse. First the battles he is fighting…

He makes it clear commissioning should not go in the core contract but should be an optional DES, which would cover a range of fairly generic stuff such as assessing referrals and prescribing for cost-effectiveness, so it could be made to work in parts of the UK where commissioning is not going to reach.

And he says commissioning should most definitely be paid for, but the money should not be tied to targets for reducing referrals or staying within budget.

And then his big concession. Dr Buckman says he would not have a ‘huge problem' with saddling GPs with routine historical debt where PCTs had failed to stay within budget, although he does have a problem with the idea of inheriting debt accumulated by Darzi centres and PFI schemes.

The question is whether these are the right battles to pick.

The concern is that Dr Buckman has identified one overriding concern – the threat to the UK-wide contract, should commissioning be written into the English version – and contorted himself into some pretty strange positions to try to prevent that happening.

Dr Buckman says commissioning in England – or at least, cooperating with a commissioning consortium – should be legally binding via the NHS Act.

He reckons a simple wording such as ‘GPs shall be involved in a commissioning consortium in England' would be enough to secure the profession's cooperation, without the need for any contractual levers to ensure that happens.

I can't help feeling that Andrew Lansley would have to be in a particularly generous mood to agree to that one. I actually suspect GP consortia might hope he does not, since cajoling disparate GP practices into working together may be tricky enough even if practices do have a contractual duty to link up.

And then there's Dr Buckman's idea for a payment mechanism – an optional DES, deliberately written so vaguely that it can apply equally to English GPs, playing an active role in commissioning, and Welsh GPs, where there is no longer even a commissioner-provider split.

Again, that wouldn't come high in my list of winnable battles. I would have thought it would be better, if a single UK-wide contract is an absolute, to accept a specific DES for England on commissioning and then negotiate separate equivalently funded agreements for Scotland, Wales and Northern Ireland.

And then Dr Buckman quite rightly argues for extra cash, and is happy to accept targets for hitting commissioning quality standards, but will not accept any money being linked to referral rates or staying within budget.

He is right on the referrals point, but wrong on the matter of budgets. If GPs have an incentive to commission the highest quality care possible, but no incentive to do so within budget, then does he really expect those budgets to be hit?

The Department of Health has a team of pretty sharp negotiators, who are likely to spot these holes in the GPC's negotiating position. And the cost of going to battle on the unwinnable is that the winnable goes unfought.

Here is my list of winnable objectives:

- A system that may accept commissioning is compulsory for practices, but does not penalise individual GPs who choose not to get involved

- Proper incentives for commissioning, to ensure it's an attractive prospect for those GPs who really make a success of it

- A sensible ethical framework, ensuring GPs are not compromised by being paid for crude cuts in referral rates, and are protected from accusations of conflict of interest without being weighed down by bureaucracy

- A lock-down guarantee that GPs will not have to take on commissioning while carrying any of the burden of PCT debt.

But I'm not pretending it's going to be easy. The Department of Health will be picking its battles too.

By Richard Hoey, Pulse editor