This year’s NHS Alliance conference had a strong whiff of déjà view. Despite the Darzi review, not a lot seems to have happened in primary care in the past 12 months. This may be because the good Lord doesn’t really understand primary care, or because GPs are sitting on their hands, trying to duck the recession and seeing out the fag end of ‘new’ Labour. Last year, the NHS Chief Executive David Nicholson delivered a rousing speech encouraging GPs to go forth and commission. But despite all the publicity for ‘World Class Commissioning’, not much seems to be happening on a practice level.
The Government appears to be losing patience with GPs, which is perhaps why polyclinics are being rushed in with indecent haste, trampling over public involvement legislation, and plonked anywhere they can get quick planning permission, before the treasury starts clawing back the NHS budget to pay for the banks we now all own. Maybe we’ll see polyclinics in disused branches of Northern Rock, HBOS, and Halifax. Or maybe we’ll combine financial and medical advice. Step this way for banking and bunions!
The Alliance Chair, GP Michael Dixon, is nothing if not an optimist, but he’s convinced that many frontline NHS staff don’t understand the reform programme and so are unlikely to implement it (or be ‘clinically engaged’, as the Department of Health puts it). Dixon was spot on when he pointed out that reform can only succeed if managers and politicians like and trust the staff. He cited his own study, which found that the important thing for patients was not that they liked their doctors or nurses, but that they felt their doctors or nurses liked them. And so it is with the staff. If all you get is a stream of negativity from Whitehall or your PCT, you’re hardly likely to do what they want you to do.
Dixon quoted the Department of Health’s quarterly survey, which found that roughly one-third of practice-based commissioners still do not have budgets, and even more have not agreed commissioning plans.1 This could well be because PCTs, having gone through one round of culling, feel threatened by GP commissioning and the prospect that the Tories might get in and reintroduce fund-holding. As the global financial meltdown has shown, people hate uncertainty about their future, and it generally leads to panic, paralysis, and stuffing bundles of fivers in the mattress.
If I was a partner, I’d be tempted to get into commissioning because if you don’t control your future, you can be pretty sure someone with less intelligence, insight, and understanding will try to control it for you. Recently, we’ve seen plans to bypass the GP gatekeeper role by allowing self-referral to physiotherapists, and plans to shore up gate-keeping by paying GPs to cut their referrals to hospital. The PCTs are panicking because GP referrals are rising, money is running out, and they want to take another chunk of your clinical freedom away. In such a climate, you’d be safest in a large commissioning consortium.
As a GP locum, I’ve got a very uncertain future—sessions are drying up as local practices issue profits warnings and opt to do the work themselves or take on cheaper nurses. I still have a very extravagant lifestyle, which I’m loathe to give up, but I have found a brilliant way to escape my spiralling debts: I’ve invited Gordon Brown to nationalise me. As of today, you all own shares in Dr Phil, in return for paying off my overdraft. If you’d like to get your money back, why not invest in a copy of my new book, Trust Me, I’m (still) a Doctor? If I sell a million copies, I’ll be able to buy myself back and settle my debt. If this plan makes any sense to you, you probably shouldn’t get into practice-based commissioning. Good luck!
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- Department of Health. Practice based commissioning. GP practice survey: wave 4 results (August 2008). London: DH, 2008. G