GP Committee of the BMA responds

The GPC have provided their response to the NHS White Paper (available here). Here are some of their "lines in the sand" principles

GPs must always provide patients with advice, investigations or treatment where necessary. The investigations or treatment provided or arranged must be based on the assessment of needs and priorities, and on clinical judgement about the likely effectiveness of the treatment options.

GPs must give priority to the investigation and treatment of patients on the basis of clinical need, when such decisions are within their power. If inadequate resources, policies or systems preclude this, and patient safety is or may be seriously compromised, the matter must be drawn to the attention of the appropriate authority.

This seems to me to be rejecting the White Paper sections 4.4 and 5.12 which says that GPS should "align clinical decisions in general practice with the financial consequence". GPs, understandably, do not want to be held accountable for any financial consequence, and neither should they be.

GPs involved in commissioning need to receive adequate resource and support to undertake the work involved in commissioning services for their patients and the wider population.

GPs are quite frightened by the potential that taking on the commissioning role will put their practices in financial risk. They are frightened that Lansley may decide that GP consortia will have to take on the debts of the PCT they replace, and that the resources being offered by the Department of Health are too limited to cover the work they will commission and so they will be liable for any overspend. The are concerned about the White Paper section (5.14) which says "the Government will not bail out commissioners who fail". The GPs are rightly worried about this because GP commissioning will be compulsory (but see below).

GPs must not accept any inducement that may affect or be seen to affect the way they treat or refer patients.

This is the GPC saying that they do not want to be seen to be using patients as cash-cows. It will be a fundamental change in the relationship between the patient and doctor if the patient thinks that the doctor regards their treatment as a down payment on their next Mercedes. It is yet another swipe at sections 4.4 and 5.12 of the White Paper. However, remember that GPs are private businesses so they cannot completely rule out the prospect of making some more dosh:

If GPs have financial interests in organisations providing healthcare these interests must not affect the way GPs prescribe for, treat or refer patients. If a GP has a financial interest in an organisation to which they plan to refer a patient they must tell the patient about these interests.

This is rather weak. It is saying that if the doctor wants to get some money out of a patient (directly, or indirectly through NHS commissioning) they can use their unique trust relationship to persuade patients that this is OK simply by telling the patient that it is so. The GPC must hold the high ground here, they should say that a GP should NOT refer a patient to an organisation where they have a financial interest. If such a referral is needed then the patient should be given a second opinion.

Consortia should be required to consider the implications of their decisions on their local population, patients within other GP consortia and the wider NHS health systems, and wherever possible, consortia should ensure that NHS providers are the providers of choice. Consortia must be committed to reducing healthcare inequality wherever possible.

This statement will upset Lansley immensely because it will kill his "any willing provider" policy and also it will render his policy of competition within the health service as pointless.

Public and patient involvement should be integral to the work of consortia. Challenging decisions concerning treatment priorities may need to be taken based on a mutual understanding of the constraints of limited resources, and the obligation to use such finite resources wisely. The consortium must be accountable to patients and the public who will need to participate in such decisions.

GPs are "scared witless" that the public will blame them for healthcare rationing. The GPC appear to think that "patient involvement" will insulate them from this criticism. Unfortunately, this is rather optimistic. GPs will be blamed.

Resources liberated from service redesign or changes in referral patterns will need to be reinvested in patient care. GPs must not personally profit from a commissioning budget surplus , which should be used for patient services. There must be no integration of the commissioning budget with payments to the practice for providing essential primary medical services under their GP contract. This will ensure that trust remains between patients and their GP.

This is the "Mercedes down-payment" argument that I mentioned above.

Practices will be expected to engage with commissioning consortia. It must be accepted that the relationship between populations, patient need, budget and financial activity is complex and in this regard consortia will be expected to act with integrity and leadership when considering the accountability of practices. No sanctions should be taken against practices where it can be demonstrated that GPs are acting within the expectations of the principles outlined in this document and where professional and contractual obligations are being fulfilled.

This is finger pointing at White Paper section (5.14), GPs are saying that if they try their best they should not be held financially responsible. There is fat chance that Commissar Lansley will agree to this.

It will be interesting what the GPC will do if they feel that Lansley has not addressed their concerns.

UPDATE:
Pulse have reported that the GPC is unhappy that the government will re-write their contract to make commissioning compulsory and "will instead push for it to be offered as an optional enhanced service".