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It’s squeaky bum time for Lansley’s commissioning plans

By Richard Hoey

Everyone is getting edgy about the delayed White Paper as the health secretary faces a fierce rearguard action over his plans for GPs, says Pulse editor By Richard Hoey

Big money, unexplained delays and rumours of behind-the-scenes angst, and all the while a shadowy presence making itself felt in the background.

It could be the final instalment of Harry Potter, or the latest Manchester United transfer rumour, but it's actually the Government's eagerly awaited White Paper on health.

If indeed it ends up being a White Paper. There are suggestions it could be downgraded to the status of a strategy paper, or a White Paper with a greenish tinge, as one ministerial source apparently claimed.

So why is health secretary Andrew Lansley having such a hard time getting his White Paper through?

Resistance to his plan to hand PCT commissioning to GP federations seems to be coming from a wide variety of sources – from panicked NHS managers, wary Liberal Democrat partners, nervous GPs and that shadowy force I was referring to, the Treasury.

Of course, what these various groups are worried about varies from one to the other, and in some cases it has been Mr Lansley's response to one set of concerns that has precipitated nervousness elsewhere. He is having to spin multiple plates, and the plates don't like each other.

A quick timeline, at least from what we can gather (or guess) from whispering sources, terse ministerial statements and the stubborn refusal of the white paper to appear:

  • The Lib Dems never were wild about Lansley's plans, for reasons outlined in this blog before, to do with concern over the level of democratic accountability in the GP commissioning plans.
  • The Lib Dems have a certain influence in the Treasury, so they may have had a hand in the subsequent rumblings to come from that department, which have centred mainly on whether there were sufficient controls to prevent GPs overspending.
  • Alarmed at the Treasury response, Lansley toughened up the accountability measures in his proposals, with GPs now facing scrutiny of their referral decisions and an expectation that they will share the financial risk.
  • Emboldened by the Treasury resistance, NHS managers then went on the offensive, suggesting the existing accountability framework was still not enough to prevent a huge NHS deficit, which the Health Service Journal rather dubiously put at a potential £1.2 bn a year.
  • And then came the surprise intervention from senior GPs at the NHS Alliance, who warned most practices weren't up to commissioning under the tough proposed accountability framework, and called for the plans to be piloted before going ahead.

The NHS Alliance has since reinforced the impression that it has rather gone off the DH plans, by suggesing GP federations won't be big enough or strong enough to take the tough decisions. But its leaders are edgy, and super-sensitive to any suggestion that the organisation has lost its nerve.

It's interesting to record the GPC's behaviour during all this. A senior GPC member slightly scathingly told me that the NHS Alliance was getting nervous not because it was worried about GP practices, but because it was alarmed for the jobs of PCT managers, who it also represents.

The GP negotiators are remaining firmly, unwaveringly behind Mr Lansley's plans, at least in principle. But they admit, of course, that they haven't seen the details yet.

They, like the rest of us, are following the rumours, and waiting.


And a quick addendum - the waiting, it seems, could soon be over. The nationals, after one of those shadowy lobby briefings that are so frustrating for the rest of us, are reporting a clutch of details about the White Paper. And everyone seems to think that it will be out on Monday.

By Richard Hoey, Pulse editor