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Profit shares will devalue general practice

By holding both the purse-strings and the stethoscopes, GPs are entering dangerous new territory

The NHS is changing so fast that yesterday's kite-flying proposal is already the new reality. Just a week or so after Prime Minister David Cameron announced that whole tranches of existing public services would be sent out to tender, and here it is happening, at a primary care trust near you.

The pioneers of plans being piloted by NHS East of England insist providers of care pathways – likely to be GPs in partnership with private firms or possibly charities – will have to meet rigorous ‘quality' targets. It's hard to object to a bit of quality, and with a few outcome targets thrown in too, there's a reassuring echo of the QOF. But this scheme, like another in Guildford also revealed over the past week, builds in another kind of contractual incentive that doesn't seem quite so harmless. It hands providers the chance to boost profits by reducing referrals and driving down costs.

Schemes like these are supposedly about provision rather than commissioning, but either way the controversy they have generated goes right to the heart of one of the key arguments of principle on the NHS reforms – and one on which GPs are divided. Health secretary Andrew Lansley argues that GPs are the right people to hold budgets and commission services because it is they who take the clinical decisions that have the greatest impact on NHS costs. By ensuring the same people hold both the purse-strings and the stethoscopes, he believes the NHS can finally control its spiralling costs, by putting money at the core of every clinical decision.

Pulse's survey earlier this month showed that 46% of GPs agreed with Mr Lansley about the principle of GP commissioning and budget holding, far more than accept his arguments in other areas of the NHS reforms, such as the need for more private competition. But there is also a growing argument that GPs could be the wrong people to hold budgets, precisely because

it is GPs who are responsible for the care of individual patients, and they therefore who face being the most compromised by the cash. Some GPs even wonder if there may have been a creative element to all that tension with PCTs, with doctors arguing forcefully for the medicine, managers for their spreadsheets, and eventually an answer reached that was acceptable to both sides.

Those were philosophical arguments, until now. But the prospect of GPs being paid for keeping patients from hospital, and potentially denying them the treatment they need, is no longer hypothetical, but there in the black and white of SHA reports, and no doubt too in the glossy brochures of corporate business plans.

It is a move the GPC must oppose. For GPs to take a cut of the savings they make by reducing referrals would undermine and devalue the profession. It also fatally blurs the line between GPs' practice funding and the wider budget for the care of the population, something Mr Lansley promised he would not do.

Patients would never again be able to tell if a GP was opting to avoid sending a patient to hospital because it was the right thing to do clinically, or because the lack of a referral was money on the bottom line.


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