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Now, Armageddon?

Losing the essence of GP commissioning due to fears about NHS marketisation is the danger of the 'pause' in the health reforms, says Dr Michael Dixon

The Health and Social Care Bill, currently undergoing a 'pause', has two elements of major importance to general practice. One is the introduction of GP commissioning and the other is the increasing marketisation of the NHS.

On the market issue, commissioners will sometimes want to create more competition when services are unsatisfactory and are not listening to the commissioners. At other times they will want to cooperate with their better providers and exert leverage to improve things further.

What matters is that local GPs and practices within a local consortium should be able to decide exactly how much of a market they need. Monitor or the National Commissioning Board should not be able to interfere with their sovereignty in this respect. All this is commonsense and Monitor appears to be rapidly losing public credibility as it speaks of dismantling public services and (God forbid!) making them like the public utilities. This needs to be sorted so that GP consortia can properly integrate services and co-operate with providers when necessary.

Unfortunately, the pause is also likely to see GP commissioning itself undergo a makeover. In some quarters, outside the NHS (e.g. in a recent Times leader), it is seen as more of a threat than marketisation.

The National Reform Review is stuffed with people, who think that GPs are not up to the job and want to put many more checks on GP commissioning. These checks will vary from, specifying representation on the local GP commissioning consortium board - nurses, allied professionals, consultants and local councillors etc., to bureaucratic suggestions as to how conflicts of interest can be managed. And other checks to ensure that consortia decisions are subject to ratification by local councils, the National Commissioning Board, Tom Cobbley and all.

The end result could be GP consortia with responsibility but no power and a shift back to centralism with senior management in control. Just as an effort to reassure the outside world that consortia are 'watertight'.

Thus the outcome of the pause could be to straightjacket and paralyse GP commissioning before it has begun and repeat all the sad mistakes of the past, which will only result in GPs working just as they have with practice-based commissioning, which failed to hand them any effective say or role.

The juxtaposition of GP consortium and market issues in the bill is therefore unfortunate because pressure to alter the latter could end up with the effective destruction of the former.

On the review panel where, predictably, secondary care clinicians outnumber primary care clinicians and where they are also outnumbered by senior managers, there will be few to speak up for GPs. Indeed some consultants will want to be on the GP commissioning boards in order to protect their hospitals and specialities and to challenge the GP ‘overlords' rather than simply improve care pathways (a task in which they will be essential).

It is not surprising therefore that some GP consortia leaders fear that Armageddon will be the outcome of the pause. 'Betrayed, 'hung out to dry' are phrases in emails sent to me by consortia leaders - the mixed metaphors illustrate strong feelings - 'We put our neck out and now we find the rug pulled out from under us'. The knives are out for GP commissioning from a wide front of self interested people and organisations and there is a real danger that they will prevail sufficiently to make GP commissioning ineffective.

We may not have helped ourselves through our own divisions within general practice. Now is the time for GPs to say with one voice, as the leaders of all the main GP organisations now are, that we do want a role in improving the health and services of our patients outside the consulting room and that GPs are uniquely placed to speak for their patients and the local population.

It is crucial for our patients that we do so and crucial for the future of a sustainable NHS. We need to change some aspects of the bill, particularly around competition and markets. But if we dilute or dumb down GP commissioning then the greatest opportunity of our professional lifetimes will have been lost.

In short, we cannot afford to lose the newborn baby of GP commissioning with the bathwater of over enthusiastic marketisation.

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

Dr Michael Dixon