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So where are those powerful incentives, Mr Lansley?

By Richard Hoey

The White Paper promised GPs would be rewarded for good commissioning, but it's now clear that at best they'll avoid having their pay docked, says Pulse editor By Richard Hoey

An incentive, according to the Concise Oxford Dictionary I have in front of me, is ‘a payment or concession to stimulate greater output by workers'.

It is, in other words, the promise of extra cash, so when the health White Paper declared there would be ‘powerful incentives' for GPs to commission effectively, more than a few entrepreneurial types were rubbing their hands.

Well, here's some news for you. The Department of Health appears to be using a different dictionary.

Its consultation paper on GP commissioning Liberating the NHS: commissioning for patients – makes clear that there won't in fact be any new money at all.

Instead, the ‘quality premium', which is to be paid to practices if the commissioning consortium comes in within budget and hits outcome targets – will be taken entirely from existing payments.

That clears up a bit of confusion over whether GP income will be at risk if consortiums overspend. It will.

It's true the plans keep commissioning and practice budgets separate, but GP practices will only preserve their existing income if their consortium avoids an overspend, cuts death rates from a range of diseases and keeps its patients happy.

As for what happens if GP consortiums manage to make savings, there's not a word.

And unfortunately, given the undoubted and exciting opportunities that GP commissioning opens up, the news gets worse.

Because the quality premium won't be paid directly to practices, but to the consortium, which will then be left with the decision of how to divvy it up.

It might decide that one practice has worked rather hard at commissioning, and hand it extra money. It might reckon another wasn't really pulling its weight, and hold back its share of the cash.

All that might be fair enough. Some practices will undoubtedly put more into this commissioning drive than others, and might well feel they should be rewarded accordingly.

I wouldn't argue – but this is quite transparently a recipe for a split straight down the middle of the profession.

The rift that currently exists between GPs and PCTs could so easily open up between consortium board members and all the rest.

Think partners versus salaried GPs, times 10.

But these plans aren't reality yet, and there is still plenty of time for GP negotiators to push back at some of these more insidious details.

General practice has always taken strength from its unity. It must now use that strength to preserve it.

By Richard Hoey, Pulse editor