Odds are against Lansley

The latest proposals to give more power to GPs may be no more successful than the last

By Nigel Hawkes

Do family doctors have the muscle, or the will, to transform the NHS in England? That’s what the Health Secretary, Andrew Lansley, is betting on in his White Paper Equity and Excellence – Liberating the NHS.

Out go an army of managers at Primary Care Trusts and Strategic Health Authorities, which are to be abolished. In come a few hundred GP Commissioning Groups, given 70 per cent of the total budget to design services afresh, saving money and improving care for patients.

Great if it works – but the NHS is weary with wizard schemes that arrive out of the blue, are tried for a year or two, and then abandoned before there is time to know whether they work or not. The new Government promised no “top-down” structural reorganisations, but the ink was hardly dry on the coalition agreement when Mr Lansley launched one. He’s had it in his head since at least 2007 and the speed at which the White Paper and supporting documents appeared indicates that this is no spur-of-the-moment decision. He really means it.

Plenty is wrong with the NHS, but what’s wrong, specifically, that GPs can put right? That is the question to ask right now.

Money is tight, and likely to get tighter, so savings through greater efficiency and the reconfiguration of services are needed. Losing managers will save some money, but many of them will be recycled to help GPs in the tricky task of planning and purchasing services, the heart of commissioning. When Primary Care Trusts were set up in 2003 with the avowed intention of involving GPs more in commissioning, they were quickly colonised by managers displaced from the health authorities, who actually knew how to do it. GPs were placed on the next rung of management down, the Professional Executive Committee, where their influence was muted.

We can expect the same process to happen again, if to a lesser extent. GPs will need help, and the least controversial place to find it will be among former PCT managers. Private companies such as McKinsey or United Health are a fresher alternative, but GPs (led by their union, the British Medical Association) are mostly opposed to any “privatisation” of the NHS.

Dr Clare Gerada, who takes over as chairman of the Royal College of General Practitioners in November, put it this way: “For most GPs, it's like rabbits in the headlights. There is also a natural disinclination to working with external organisations, for fear of going to the dark side and being part of the privatisation agenda.”

Remarks like this overlook the fact that most GP practices are already part of the dark side, but pretend they’re not.  Contracting GPs run practices whose profit – the difference between what they are paid and what it costs to deliver the service – is their income. They are small businessmen (or in many cases, not so small), given a franchise for life. They employ jobbing GPs to do a lot of the work, at roughly half the income they are earning. They are not listed as civil servants, but they still collect a public service pension when they retire.

Yet in a display of hypocrisy that has few equals in British society, they rail against the very idea that profit-making companies should be allowed a toe in the door. And, staggeringly, they get away with it.

Any group of people capable of pulling off this trick demands respect. GPs have played the system like Paganini the violin: spellbindingly. But putting them in charge implies that they are not part of the problem in the first place.

In reality, the variation in quality between GPs is probably at least as wide as that found anywhere else in healthcare. Some are excellent, many very good, and some are awful. How could Harold Shipman murder more than 200 patients undetected, and be regarded as a kindly and effective GP? Only in the world of primary care, the least-examined part of the entire healthcare system.

We could save a lot of money if all GPs were as effective as the best, but this reform is likely to stymie all chance of that. PCTs, and health authorities before them, have failed to root out poor performers. They don’t even know with any certainty which are poor and which are good. The revolution in inspection that has run through the hospitals, revealing some horrors along the way, has barely been attempted for GPs.

Under the reforms, GPs within the commissioning consortia will be responsible for identifying bad GPs among their fellows and doing something about it. How likely is that?

So the reform risks excluding primary care from change, while giving GPs a fresh opportunity to rewrite their contracts. Mr Lansley needs the GPs more than they need him. Do not expect to see any sort of crackdown on quality, or a rebalancing of the books by abolishing the huge variations that exist in payments to practices. Some are paid twice as much as others, per patient, to deliver the same service. Why? I asked Camden PCT this very question last year after it had published a list detailing how much it paid the GP practices in its area, and got no answer. Are the top earners better? If so, how does anybody know? Or are they just luckier?

When the new GP contract came in in 2004, it was meant to eliminate these variations. But it was realised at a late stage that doing so would make some practices unviable – including, no doubt, the one that serves a couple of hundred royal servants who live and work in Buckingham Palace. Faced with the politically unappetising prospect of GPs going bust, the Department of Health introduced the Minimum Practice Income Guarantee (MPIG). No practice would earn less than it did before. MPIG is still with us six years later and no closer to abolition. I suspect the new arrangements, once negotiated, will throw up an MPIG Mk 2.

If greater efficiencies in primary care are unlikely, how about the hospitals? There are too many of them, especially in cities and extra-especially in London. Yet any move to close them, or even to close services within them, is bitterly and usually successfully resisted. Mr Lansley himself has just stamped out the last Government’s reforms in London, inspired by Lord Darzi, which would have moved care into polyclinics to save money. He knows that hospital closures spell political doom.

But without some substantial changes in the numbers, disposition, and services of hospitals, savings will not be made. Dr Nicolaus Henke, director and head of healthcare practice at McKinsey and Co - the consultancy that helped design the now-junked London plan -  told delegates at a conference organised by the think-tank Reform this month that GPs' ability to cut spending would be crucial.

Dr Henke said the creation of GP consortia was likely to lead to hospital ward closures across the country. “We would need to believe that these consortia can be cheaper but equally effective systems, which make it possible to close enough hospital services,” he said.

If he’s right – and most analysts agree with him – then Mr Lansley has set the GPs to cut the ground from under the feet of their consultant colleagues.  That’s not how the BMA sees it. The chairman of the BMA’s GP Committee, Dr Laurence Buckman, has urged his GP colleagues to work closely with “our consultant colleagues at both national and local level.” A war between GPs and consultants would split the BMA, so we can be safe in assuming it’s not going to be declared.

Some GPs may be up for it, but the majority won’t be. As the truth sinks in, many may wish to avoid the responsibility for commissioning, but there is no escape. Every GP practice will be assigned to a Commissioning Group, whether it wants to be or not. And every member of every Commissioning Group will be legally and financially liable for the decisions taken.

With all NHS reforms, the experienced punter puts his chips on red, for failure. Not all actually fail, but that’s the way to bet. GPs in Mr Lansley’s exciting new world may be soon be casting jealous eyes towards Scotland, Wales and Northern Ireland, where health policy is devolved and none of these changes have been embraced.

28 July 2010

Nigel Hawkes. Director of Straight Statistics and former Health Editor of The Times,