Monday, 12 July 2010

NHS White Paper

(For an article in Pulse Magazine)

Just read the NHS white paper and it looks like we GPs can finally stop being back seat drivers of the NHS and have a go at the wheel. Well I say we, I really mean GP Partners. Salaried GPs will still be trying to fill the whole left by the GP Partners who have gone on to become new NHS managers, play golf or sit in the staff room with their feet up. Locum GPs like me will fill the whole left by all the burnt out salaried GPs who can’t take it anymore, and the gaps left in the rota by GP Partners playing golf.

Of course I am being my usual cynical self, its not all bad. I am sure great good can be achieved over time but the level of re-organisation required for the NHS mark II (as I like to call it) is quite terrifying. It won’t be cheap so how we can save £20 billion and reorganise the NHS simultaneously is anyone’s guess. I’m hopeful that GP Partner numbers will increase fairly dramatically as I don’t think salaried GPs will want to get hands dirty without a hefty pay rise.

I’ve heard other GPs talk about it being a bit like fund-holding all over again, but this it is compulsory. All GP practices will be forced to be part of a GP consortium. There they will have to fight it out, argue, arm-wrestle or do whatever GPs are going to do to decide where the money goes to. No longer can you fob off your patients and say the PCT has pulled the funding for tummy tucks, it will all be your fault. Now when you see a patient needing an operation you’ll be thinking how much this is going to cost and how much abuse will I get at the next GP consortium meeting for referring them.

Patients are meant to have control over their medical records and can go to whomever they want, wherever they want for an opinion. Practice boundaries are to be abolished - its nice to see the government listened carefully to all the objections to this problem, then ignored them, screwed up the bit of paper it was written on and then burnt it.

You’ll be over-joyed to hear patients will have choice, choice and a bit more choice with added choice on the sides and sprinkled on top. Apparently patients like to choose. It doesn’t matter that all that choice is expensive, unnecessary and a bureaucratic nightmare. Almost always when I’ve asked patients about where they would like to go to its wherever is nearest. Regardless of the fact that the nearest place doubles as a butchers shop at the weekend and offers a 2 for 1 special on MRSA and C.dif infections

Of course there will be some GPs who will be positively tumescent at getting their hands on a big pot of cash to play with. I wonder how quickly their tumescence will shrivel when they realise they’ll get the blame if it all goes breasts skyward.

However, GPs are well known for agreeing on everything, their lack of financial motivation and running multi-billion pound budgets. I honestly can’t see anything that could go wrong.


  1. "I wonder how quickly their tumescence will shrivel when they realise they’ll get the blame if it all goes breasts skyward."

    I share the tone. I have the fear. I haven't had time to look properly yet so won't talk at length but the quote I pulled out seems key.

    If the consortia (and the *members* of the consortia - no hiding behind corporate liability or some such) are held responsible somehow for failing to meet the "outcomes" that we're told will improve then this will make more sense than it seems to be to be doing just now.

    They won't be of course - and I don't even think that they should be. But at first glance the argument and the ideological underpinnings would only make sense if they were.

    Of course a defensible and independent way of *measuring* those outcomes that the rewards/punishments should depend on won't come cheap.

  2. I also need to read the detail, but a couple of observations:

    1) There is a fundamental tension between the patient knows best 'nothing fir us without us' principle and the reality that ultimately it is GPs who will now hold the budgets and be even more powerful. This still seems to be giving the message that Doctor knows best. One of the weakest aspects of practice based commissioning was the lack of patient involvement in influencing GP's on what they should buy. It will be interesting to see how GPs approach the challenge of working with and listening to patient and service representatives in a systematic way rather than relying on the views expressed by the more articulate during consultations and visits.

    2) There is a sad volume of evidence that the Doctor or GP does not know best. I am still coming across GPs who don't believe in mental health problems, think dementia is just a natural consequence of old age and doesn't require assessment, diagnosis or treatment. There are still some very prejudiced views towards those with learning disabilities amongst GPs out there and the danger is that these groups will be forgotten about. The worst GPs have a totally cavalier attitude to NICE guidance and evidenced based commissioning. Admittedly I'm extrapolating from my personal experience here but anecdote and gut feel seem to be the GPs preferred way of making commissioning decisions. Perhaps this will change once they realise the limited NHS resources are theirs to manage.

  3. And in terms of commissioning for people with mental health problems and dementia a purely medical approach is unlikely to succeed. Instead if GPs are really going to make a difference they will also need to manage social care funding. It will be interesting to see how local councils take to the idea of allowing GPs to manage *their* element of funding in eg a Section 75 pooled health and social care commissioning fund.

    Commissioning services at present has some fundamental syst design flaws. No need to go into a boringly technical discussion here about the challenges of unpicking a block contract with eg a major NHS mental health or community provider which combined with the forces of local politics and public sentiment make it nigh on impossible to decommission anything at all. But the point is, thiscreorganisatipn doesn't address any of these issues. Instead it hands the whole poisoned chalice over to a new set of inexperienced hands. If I were a provider right now, I would be rubbing my hands in glee - the govt's removed performance targets which although I could game through a bit of queue mgmt at least meant I had to go through the motions of looking like I wanted to offer a reasonable service. Meanwhile those demanding PCT commissioners, all too familiar with the tricks we play with stats and performance figures, aren't going to be focussed on holding us to account. Anyway they're off soon and it's a new set of inexperienced GP bosses. And even more helpfully this is all taking place at the same time that we've got to make enormous effieciency savings. With noone there to keep an eye on us, we won't even have to pretend we're doing something clever with workforce and pathway redesign we cam just shut a ward or service or two. Who cares that's going to lead to a breach of our contractual responsibilities, certainly not all those PCT commissioners desperately trying to calculate their redundancy pay. Yep, the next two years of shake-up and chaos will give providers faced with their own financial prssyres, free reign to cut services. Like an elaborately orchestrated distraction in a cunning bank robbery, we're all so focussed on the staged distraction going on in commissioning we'll miss the real thievery of services happening in provider-land.

  4. I remember the time of fund holding GPs... needed Physio.... sorry chum, no money left for Physio this year. Money all spent on elderly care, young chap with broken knee... fortunately no long term issues from lack of physio... but there could have been and where are the economy savings in that.

  5. "choice, choice and bit more choice"..or so they say. I like this article. :)


  6. I can't work out if the Health Secretary truly believes his rhetoric about the GPs running the budget or not. Either way this is an inspired move by the politicians. If the GPs do a fantastic job then they can pat themselves on the back and say how wonderful they are for coming up with such a brilliant idea. If the GPs do a terrible job, then they can blame GPs (taking into account the fact they have already portrayed them as money grabbing fat cats), reduced public confidence in General Practice, and use it as a stick to bash GPs for years to come. Furthermore, budget cuts? "Well, if the GPs were smarter about allocating money then you could have had your cancer treatment". For politicians it's a win win win. As a GP, I want to see patients not manage budgets, I'm better at seeing patients (just my personal viewpoint). Sure I have some very good ideas about priority for my patients, but I want someone who controls the budgets, and knows how to manage that stuff, to actually listen (rather than pretend to listen) to me and other clinicians and manage accordingly. There may be GPs who have this level of business / management acumen but enough to run the NHS? This could be a great opportunity or a huge albatross around GPs necks for years to come. GPs, patients, other NHS staff need to all voice their own opinions, positive or negative. We should all think about it and not be just passive, the repercussions (good or bad) will last a long time for all of us.

  7. Good to see you've mentioned pulse magazine, I think your readers would also be interested in Pulse-Learning the online learning resource for GPs to earn CPD credits for clinical, GP commissioning and practice business topics and develop their knowledge and skills.