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So what kind of local NHS do you want?

Pulse's investigation takes us beyond the dry language of the health bill and finally reveals the emerging new world of general practice.

Postcode lottery, inequality, fragmentation, privatisation. The criticisms of health secretary Andrew Lansley's plans are already familiar to the point of hackneyed and the reforms have not yet even passed into law.

But Pulse's investigation this week looking at 25 of the first GP pathfinders takes us beyond the bone-dry language of the health bill and the crude sloganeering of political debate, and finally makes the new world of general practice a vivid reality. As is often the case, there is more than a grain of truth in the cliches.

Mr Lansley's intention to step back and allow GP consortia to develop commissioning as they wish really has led to a huge variation in approaches, and genuinely will allow the private sector to encroach far deeper into the fabric of the health service than it has ever managed before.

GP consortia always were going to develop their plans according to the specific needs and nature of their local areas, and that's as it should be.

There's no point attempting to move swathes of care out of hospital in a highly rural area where community centres would be so small that they'd be unviable. Whether to outsource HR work to a private company will depend partly on the quality of your local NHS managers, and of their corporate competitors.

But it is hard to avoid the conclusion, from the pathfinder plans drawn up so far, that choices over how to gear up for commissioning are being driven not only by local practicalities, but by the different ideologies of the consortium leaders.

Some consortia are being open in their intention to keep the private sector ‘at arm's length'. Six of the 25 plan to use only NHS managers across the seven areas of commissioning support we asked about – including accountancy, tendering, contracting and referral management.

Others have a radically different approach, and one bound to leave many grassroots GPs feeling squeamish. Three consortia are gearing up to use external support in six or more areas of their commissioning work. It is uncomfortable for a profession that has always stood strongly against the creeping rise of the private sector to find some arch privatisers in its midst.

Where then does this leave the mainstream majority of GPs, as they watch their local health service being reshaped before their eyes? The inevitable tensions between practices and consortia are already breaking out into full-blown conflict, with GPs in Berkshire and Buckinghamshire hitting out this week over what they perceive as their exclusion from key commissioning decisions.

Is the solution for GPs to take to the streets, with placards emblazoned with those familiar slogans? It might well be, but their protests may turn out to have more traction closer to home.

Now is the time for GPs to decide how they want their local health service to look. They must consider what the NHS means to them, and how much private involvement they are prepared to countenance.

And they must make sure the message gets through, clearly and unambiguously, to their consortium leaders.


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