Dr Phil Hammond, broadcaster and sessional GP in Bristol

Can GP consortia sort out variation in healthcare?

Have you ever had the feeling you’ve been left holding the baby? I’m all for clinical staff controlling NHS money, but when you do a White Paper wordsearch (far quicker than reading it), this devolution of power looks a trifle uneven. Midwives get 1 citation in Liberating the NHS, nurses 2, pharmacists 2, consultants 5, and GPs … 75. ‘Manage’ receives 43 citations, but ‘manager’ only 3. We GPs, apparently, can do it all by organising ourselves into ‘consortia’ (a new entry with 64 hits).

Andrew Lansley has picked up the Tory baton from when it was discarded 13 years ago; just as fundholding GPs were pooling themselves into multi-funds, only to be scrapped by Labour and replaced by PCTs. In 6 years as shadow health secretary, Lansley has had his ear bent incessantly by GPs complaining about the control-freakery and lack of clinical understanding of PCTs. So he’s calling our bluff, taking out the SHAs, the PCTs, and half the quangos, and giving us responsibility for commissioning nearly everything, while saving £20 billion and making sure the mighty foundation trusts don’t hoover up what’s left.

There are similarities to previous White papers, such as Frank Dobson’s 1998 bestseller, A first class service, which gave us 191 mentions of ‘quality’ and promised to publish outcomes to end unacceptable variations in healthcare. A decade later, Lord Darzi gave us High quality care for all, with 359 exhortations of ‘quality’ and a warning that the unacceptable variations that have grown up in recent years must end. Lansley is also a firm believer that the way to achieve ‘quality’ (110) and to end ‘unacceptable services’ is to publish ‘outcomes’ (85). But after 13 years of Labour, we have precious little access to robust and valid comparisons of different clinical services. And without outcomes, offering patients ‘choice’ (Darzi 62, Lansley 84) is pointless, and you can’t ‘commission’ (Lansley 184) excellent services.

There will always be variation in healthcare; collecting and analysing outcomes to try to understand which variations are due to chance and which to unacceptable practice are both complex and expensive. And even if you have the outcomes, you still have to buy services at a price that represents value to the NHS. The Commons’ Health Select Committee concluded that commissioning under both Labour and the Conservatives before them, had delivered ‘20 years of costly failure’. So can GPs do it better?

The NHS will always need excellent management, and my guess is that in the SHA/PCT shakedown, there will be a battle between foundation trusts and GP consortia to appoint the really good ones. Traditionally, large hospitals have had all the power and the Alex Fergusons to go with it, while PCTs were left with the Sam Allardyces and a fight against relegation. Alternatively, GP consortia could decide to hand over all their commissioning woes to the big private players, which Labour is now bleating about, but it was precisely what they toyed with doing. Personally, I think we should integrate primary and secondary care, and healthcare and social care, and make these difficult decisions together.

General practitioners have always seen themselves as NHS gatekeepers, managing as much illness as possible in the community, but emergency admissions to hospital are up by 12% and unless we can put a brake on this, we’ll be taking on an impossible job. It’s a bit like being handed the steering wheel just as the runaway coach approaches the cliff edge. ‘No, thank you.’ ‘But I insist.’ Amid all the financial pressure, it’s hard to see who will find the money to collect and analyse comparative outcomes in a meaningful way to guide commissioning and choice. Lansley’s catch phrase of ‘no decision about me without me’ sounds great for ‘patients’ (217). But then he took down SHAs, PCTs, and quangos without consulting any patients. And if you asked me which of my local hospitals is best for, say, hip replacements and which is ‘unacceptably poor’, I haven’t got a clue. I’m not even sure about my own competence. And I’m supposed to be in charge. Now I must find out which consortium I belong to.G

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