Putting GPs in control of the health care purse strings

And Conservative health secretary Andrew Lansley has made clear he means it. In an interview with Martha Kearney on the Andrew Marr show last month, he spoke with passion about stripping away bureaucracy, getting rid of tick-box targets, and putting control into the hands of GPs and patients instead of managers.

“The principles are very straightforward,” he said.

“Firstly, patients should exercise more control over their own healthcare; decisions should only be made about us with us, and no decisions about us without us. And the second principle is the people we trust – we trust the doctors and nurses, GPs, hospital consultants, hospital nurses – …. shouldn’t we actually expect that they have responsibility for making decisions about our care?

“And then the third thing is, let’s get rid of this tick-box target culture and the bureaucracy that went with it. Let’s focus on the outcomes.”

It all sounds sensible, even exciting. But devil is in the detail. And the problem is that we don’t have much.

It isn’t even clear – at least not to the man in the street – just how much the shake-up will save. Mr Lansley claimed to have identified £1 billion in savings, money which would be redirected from bureaucracy to frontline health care. In a letter to top health managers, however, Sir David Nicholson, chief executive of the NHS in England, talks about making the “required productivity savings of £15-£20 billion”.

The White Paper remains frustratingly vague. A series of consultation papers which have been published on the Department of Health website, meanwhile, suffer from the opposite problem: they are dense and obscure.

The thrust of Mr Lansley’s proposals is to strip away two whole tiers of bureaucracy – strategic health authorities and primary care trusts – and replace these with local consortia of GPs, who will manage their own budgets and commission hospital treatment.

It is all going to happen very fast – the consultation period ends at the beginning of October, and the first GP consortia will be exercising “significant levels of responsibility” by next spring, according to Sir David Nicholson.

All GP practices will be expected to be part of working consortia by April 2013. Strategic health authorities and primary care trusts will be phased out over a similar timescale – so that leaves many health managers facing the threat of redundancy.

What we don’t yet know is how many of them will be simply taken on by the new GP consortia. We don’t know how many of these consortia there will be, or how big they will be. And we don’t know what will happen if they overspend their budgets, or fail to meet local health need.

To try to make sense of the reforms we spoke to two local health experts.

The former hospital boss

Changes to NHS structures alone will not improve your health or mine

BOTH the Conservative and Labour parties have a long history of tinkering with the structure of the NHS, says Alan Maynard, a professor of health economics at the University of York, who retired as chairman of York Hospital this year. The trouble is, it never seems to make much different to what matters most – the quality of care the NHS provides.

The question we should always ask, he says, is will change mean better care for patients.

“Will we lead longer and better quality lives as a result. But there is very little evidence that changing the structure of the NHS – whether it was the Tories or Tony Blair – improved your and my health outcomes. There is a belief that this [the coalition Government’s health reform] will make the NHS more efficient and give better cost control. But there is no evidence.”

He fears this could be the wrong time for such sweeping reforms. The country is in debt; there is pressure on local authorities to reduce spending, which will mean less social care and conceivably more elderly patients blocking up hospital beds; and a steadily ageing population needing ever more healthcare.

All these could put the financial balance of the NHS at risk, he says.

Under the reforms, GPs will effectively act as gatekeepers for health care. They, and not faceless managers, will have keep a lid on health spending. That could lead to ethical dilemmas for some GPs, with their duty under the Hippocratic Oath to do their best for patients conflicting with their need to control costs.

If they overspend budgets, GPs could be penalised financially, he says. One of the consultation documents in support of the white paper makes this clear. “We… propose, subject to discussion with the BMA and the profession, that a proportion of GP practice income should be linked to the outcomes they achieve… and the effectiveness with which they manage financial resources,” it says.

Some GPs may well welcome their new role, Prof Maynard admits. “But some will think ‘I much prefer to just look after patients’.”

If there has to be reform, Prof Maynard believes a real chance has been missed. It has never made sense to him the way the management of primary care (GPs, health visitors and district nurses) is separated from secondary care (hospitals) and from social care (social services and other services for the elderly and vulnerable provided by local authorities).

These should all be streamlined so there is a single ‘pathway of care’, he believes.

There is nothing in the White Paper to suggest that is a priority.

The GP

Less talk and more action after the GPs take over

ACOMB GP Brian McGregor doesn’t agree that the coalition Government’s health reforms are being rushed through.

“Andrew Lansley has had six years as shadow health secretary. These proposals came out eight weeks after they came into power. I think they have a very clear idea of what they want,” he says.

Yes, the vice chair of the local medical committee which represents GPs admits, there is a lot of detail still to be thrashed out.

But in broad terms, he thinks the proposals could be good for patients. In effect, the GP consortia – it is possible that there may be a single one for York, though that is far from clear yet – will be mini local health authorities run by doctors. They will be clinically driven, not manager driven.

“There will be less talk, more action,” he says. “You’re going to get decisions made by clinicians [GPs] who will look at evidence of what is and is not effective care. They will be basing that on the patients in front of them.”

Patients will be more involved in decisions about their care too, he says.

But if it is GPs managing health budgets, won’t it put them in a difficult position when they have to tell patients they cannot have a certain treatment?

“We are going to have to learn to say no more often,” he says. But to an extent GPs already do that. And it will be up to them to explain the difficult choices doctors have to make.

At least as commissioners, GPs will have the flexibility to respond to different local needs. With targets being relaxed, for example, they might decide that it is okay to wait 20 weeks rather than 18 weeks for a hip replacement – if, once it is done, the hip is replaced properly, and the longer wait means more can be spent on another area of health care.

Dr McGregor sees a number of other potential benefits to the reforms. GP consortia will be expected to talk to local authorities – so there should be less of a divide between health and social care. And he is confident the consortia will work closely with hospital doctors too. “It will make for much more joined-up thinking.”

There is a concern that GPs may lose out financially if their income is indeed linked to outcomes and financial management, he admits. “We hope that they are not going to turn around and ask GPs to pay out of their own pockets for services to patients.”

With PCTs and strategic health authorities being phased out, he is also worried about a potential brain drain of managers from the health service.

NHS North Yorkshire and York could lose 45 per cent of its managers over the next couple of years, he said – more than 200 jobs. It is still unclear how many of those will be taken on by the new GP consortia.

“That’s the biggest threat to the NHS at the moment. There are some excellent managers with a wealth of knowledge. I fear that we will lose some very good individuals to private industry.”

But one thing he will welcome is the opportunity for GP consortia to invest more in preventative care, and in public health work to stop people becoming ill in the first place.

And providing the new GP consortia can work together with local authorities and hospitals, they will be able to develop an “efficient, high quality package of care for patients,” he believes.