The NHS turned upside down

Andrew Lansley’s new White Paper ‘Equity and Excellence: Liberating the NHS’ is being described as “the NHS turned upside down” by a leading health commentator.

David Cameron has made no secret of his desire to roll back the state – but was careful in opposition to try and reassure voters that the NHS would be safe in his charge. The Coalition document even promised “no top down reorganisations” for the NHS. Instead, two months on Andrew Lansley’s new White Paper ‘Equity and Excellence: Liberating the NHS’ is being described as “the NHS turned upside down” by a leading health commentator.

The main proposal is to make GP “consortia” take over budgets for NHS services from local Primary Care Trusts (PCTs). £80 billion of public money is to be given to GPs from primary care trusts to commission NHS services from 2012 – by assessing local need, setting contracts for local health providers and monitoring those standards. This builds on the Tories’ GP fundholding of the early 1990s which had high transaction costs and led to differential service standards between GP practices.

There are some fundamental conflicts of interest in giving GPs the final say over real funding streams: GPs are independent contractors, running businesses seeking to maximize income; they will also now hold massive budgets which they may choose to spend much of on services they run themselves.

Yet there is a more fundamental problem: most GPs do not want the hassle of strategic planning, negotiating multi-million pound budgets and making unpopular decisions about NHS service organisation and costs. In fact, clinical commissioning as an idea is nothing new – for the last five years Labour ran Practice-Based Commissioning (PBC), a voluntary scheme that allowed GPs considerable influence on how services are commissioned, but with PCTs having the final say.

By any objective measure, progress has been challenging: the Department of Health’s recent survey results highlight a decline in interest in PBC and a consistent minority of GPs who actively oppose the principle of GPs getting involved, such that the DH’s  lead GP referred last autumn to PBC as “a corpse”.

Yet the White Paper is thin on detail, with key points unclear. Will GP consortia be allowed to retain budget underspends; and what will happen if they overspend their budget? Not insignificant questions given this proposal coincides with what even Nick Clegg admitted at the weekend was “an extraordinarily tight settlement for the NHS”. How will regulation be undertaken? Again, the detail is absent.

Could this White Paper mark the beginning of the end of the NHS, or is it hyperbole to suggest as much? Certainly the principle of a service based on needs, and free at the point of use remains. Standby, however, for rows during  this Parliament – on the “postcode lottery” of differential service standards now likely to develop, and on health top-ups, such as for expensive drugs or faster access to services.

And not forgetting the prospect of those private sector companies required to “support” GP commissioning consortia being allowed to refer to their own (or arms’ length) providers’ services who run private hospitals, primary and community services.

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