Dr Phil Hammond, broadcaster and GP returner in Bristol

GP commissioners need to focus on preventive strategies

Who’d be a GP commissioner? A pointless question, I guess, since it’s compulsory and soon we won’t even have PCTs to blame when the money runs out. Journalists, pressure groups, and disgruntled NHS managers have wasted little time in voicing their concerns that GPs aren’t up to the task, but Andrew Lansley’s not for turning so I guess we’ll just have to get on with it.

One big problem for the new GP consortia is that, as things stand, they’ll inherit the deficits of both PCTs and practice-based commissioning (PBC) experiments. According to GP magazine, a third of PCTs had deficits at the end of 2009 totalling £130 million and others were hiding debts by borrowing money from other trusts.1 So rather like a new political administration, GPs will only know the true extent of the debt they’ve been saddled with when they sit down and study the accounts.

Even if the debts were written off, doubts remain whether we can balance an £80 billion commissioning budget. An investigation by Pulse magazine found that PBC had cost the NHS £250 million more than it had saved,2 largely because GPs had found it difficult to shape the services that their patients need. Of course, this may be easier when the PCTs get out of the way. Finally, the Health Service Journal scrutinised the commissioning spend of 190 GP consortia during 2009–2010, and found an overspend of 2.5%, equivalent to £2 billion if we were controlling the whole budget.3

Faced with such a complex commissioning task, I think we should all slow down and do things at a sensible (i.e. non-politically driven) pace. Although the Tories are keen on choice, as New Labour were before them, in tight financial times I can see more hospitals merging to form hugely powerful super foundation trusts that stamp out most of the competition. Faced with such powerful neighbours, GP consortia will also be forced to merge so they don’t get played off against one another. So we’ll end up with one huge purchaser for every massive provider, and the power will rest largely with who recruits the best managers before they skip off to the private sector.

So what’s the point of it all? GP commissioning is unlikely to affect choice of hospital, which is what many patients are bothered about. But we really could save money if we could shift services upstream and keep people out of hospital. The best PCTs and GP commissioning pilots already have integrated services that do just that, which is why we need to take time to learn from what’s already out there. If we really want to break the secondary care monopoly and have the ‘primary care led NHS’ that we’ve been talking about for 20 years, we have to come together in sufficient numbers, take responsibility for the budget, gather the best data, cooperate with hospital colleagues and other community providers, and manage the healthcare of a large population, not just the few thousand on our list.

Prevention may not get the adrenaline pumping as much as major trauma, but it’s the only thing that can keep the NHS afloat. Just think of any admission to hospital as a failure, and work backwards to see if that fractured femur/suicide attempt/heart attack/casualty attendance with a cotton bud in the ear could have been prevented. Once you’ve figured out how, find out where the incidence hotspots are, and then commission handrails in the nursing home, counselling on the sink estate, dog walking around the takeaways, and reclassify cotton buds as a class A drug. Good luck, and let me know how you get on.

  1. Ireland T. Consortia ‘will inherit PCT deficits’. GP 2010; 20 August: 1.
  2. Lacobucci G. PBC costs NHS £250m more than it has saved. Pulse 2010; 70 (24): 1.
  3. Gainsbury S. GPs’ £2bn threat to commissioning budget. HSJ 2010; 26 August: 4–5. G

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