Health Reforms: Family doctors to prescribe shake-up for NHS

GPs will decide how 80bn in taxpayers' cash is spent each year on the bulk of NHS services and will rule on what will be provided and where.

Decisions will no longer be taken by NHS managers or indeed politicians, as Whitehall who will give up powers to micro-manage local NHS care.

Ministers argue that GPs are best placed to make decisions on behalf of their patients as they know best what works locally.

But critics point out there is no evidence they will make improvements in patient care and warn the national element of the NHS will be undermined as services develop piecemeal, leading to big differences across the country and further reducing equality of access to care.

Above all the changes will be carried out at a time when NHS finances come under unprecedented pressure due to a funding squeeze which means 20bn must be saved by 2015, prompting criticism the reforms should not be the main priority for the NHS at this time.

GP Peter Melton will be among the vanguard of doctors taking on new responsibilities. He is already interim chief executive of Grimsby-based North East Lincolnshire primary care trust (PCT) and will take a leading role in the new local consortia of GPs which will take over from PCTs in April 2013.

He said until now GPs had been forced to focus on the organisational priorities set by others in Government or in management, which could differ from what local GPs felt was important for their patients.

Decisions taken by GPs played a key role in how NHS money was spent – but, until now, the accountability for those decisions had rested with managers.

Under the new arrangements, he said GPs would be accountable for their spending and be able to work with their peers to make decisions about how patients were treated and services run.

Although the reforms are not designed as a means to save money, he said if GPs at 30 practices in the area all performed as well as the top 25 per cent in prescribing drugs and making patient referrals, it would save 9.3m alone each year which could be re-invested in existing services or new treatments. "Locally we are very enthusiastic about the changes," he said.

"All practices will work together to share and learn from one another."

But the biggest stumbling block remains the efficiency drive which will mean savings of around 2bn in Yorkshire.

Tens of thousands of administrative staff will go nationally but their departure will only pay for a small part of the savings widely seen as the biggest challenge ever faced by the NHS.

The next two years are likely to prove extremely difficult as cuts lead to increased waiting times and services are axed prompting increasing public anger. There are already signs NHS finances are deteriorating and they could plunge into chaos as managers struggle to maintain control.

Chris Ham, of the independent King's Fund thinktank, said yesterday: "The last decade has seen significant progress in the performance of the NHS. While Ministers are right to stress the need for reform to make it truly world class, these gains are at risk from the combination of the funding squeeze and the speed and scale of the reforms as currently planned.

"GPs are well placed to understand the needs of their patients so giving them a leading role in commissioning services makes sense. Strengthening the link between clinical and financial decision-making could lead to improvements in patient care and could make services more efficient.

"Finding the 20bn in efficiency savings needed to maintain services must be the overriding priority, so the very real risk that the speed and scale of the reforms could destabilise the NHS and undermine care must be actively managed.

"The real choice is not between stability and change, but between reforms that are well executed and deliver results for patients, and reforms that are poorly planned and risk undermining the NHS."

COMPETITION

PRIVATE business could take a large slice of the NHS cake under the Government's reforms proposals.

NHS services will be opened up to competition to be run by "any willing provider" in a move Ministers believe could stimulate innovation and lead to new models of care designed around patient needs.

But doctors' leaders say GPs could be forced to open NHS services to competition even if they believed the "best and most appropriate" services could be provided by local hospitals.

The British Medical Association said this could ultimately damage local services.

Private firms are likely to find high-volume, low-cost services the most attractive, potentially leaving local hospitals with more complex and expensive cases as well as emergency care.

Health services are highly interdependent and decisions could ultimately undermine a hospital's financial viability, putting services at risk.

At the same time, providers will also be able to compete on price, allowing them to offer to provide services at lower rates.

Critics claim this would lead to a "race to the bottom" amid international evidence that cheaper care is linked to worse-quality care.

Claire Gerada, chairman of the Royal College of General Practitioners, said it made sense to give GPs, hospital specialists and social care experts responsibilities for planning and setting up new services. It supported "co-operation, collaboration and competition but only where it adds value".

"We must guard against fragmentation and unnecessary duplication within a health service that is run by a wide array of competing public, private and voluntary sector providers, that delivers less choice and fewer services, reduces integration between primary and secondary care and increases bureaucratic costs," she said.

MANAGEMENT ROLE

CRITICS of the reforms point to concerns about the capability and willingness of GPs to take on new responsibilities.

Most family doctors are independent businesspeople and are not NHS employees.

They have faced increased performance monitoring in recent years, but little is known about how effective they are in delivering good outcomes for their patients or their management skills.

And yet they are being given the pivotal responsibility for how 80bn in public cash is spent.

Some GPs are very enthusiastic about the reforms which they see as freeing them from diktats from politicians and NHS managers.

But significant numbers are opposed to the plans and perhaps the majority are agnostic. The NHS Confederation, which represents NHS trusts, said low involvement by GPs was among the biggest threats to the success of the reforms.

In practice, serious disagreements are also likely to emerge between groups of GPs involved in new consortia leading to problems in decision taking, while links with hospital doctors, who apparently have no role in the new arrangements but could see their services stripped away or radically altered, could also be damaged.

Above all, the relationships between GPs and their patients could also be undermined.

Family doctors will be responsible for tough decisions, from which drugs to pay for to how services are organised. This could include refusing to pay for life-saving medication and in some parts of the country it will certainly mean the closure of entire hospitals. These will not be for the faint hearted and doctors will come under severe pressure from the public as well as politicians.

Despite their new freedoms, decisions will also be closely linked to how much money is available – and that will remain in the hands of politicians.

Given the parlous state of public finances, taking control of running the NHS could turn into a poisoned chalice.

POLITICAL INPUT

MAJOR problems will arise in the NHS in coming years but who

will sort them out remains unclear.

In the next two years, tight central controls are being imposed by a new NHS Commissioning Board to try to rein in health service finances as key personnel leave primary care trusts.

The board, at arms length from the Department of Health, is being set up partly to reduce political interference in the NHS.

But its exact relationship with Ministers remains to be clarified. Doubts remain if it will devolve powers to the front line and it could simply behave in the

same way as the Department of Health.

Ministers and Whitehall will lose day-to-day control of services but history suggests politicians will be tempted to intervene in contentious decisions.

Family doctors will take charge of spending decisions in 2013 but it is unclear how they will be monitored or what happens if they are seen to be failing.

GPs are unused to public scrutiny but due to their new role taking important spending decisions, they will have to engage with the public and also be prepared for criticism over decisions which could include moves to downgrade or shut cherished public services.

Every hospital will also be made independent by becoming foundation trusts despite doubts they will be able to survive on their own.

New health and well-being boards within local councils will be set up which Ministers claim will give "real democratic legitimacy" in the shaping of local services by bringing together NHS, public health and social care leaders.

Joint working across NHS and local council boundaries will be vital due an ageing population and public health epidemics including obesity and heavy drinking.

Patients will be given a role in new Healthwatch organisations but these will need to be significantly better resourced than their predecessors if they are to be effective.