Enthusiastic, or Bullied Pathfinders?

In Cameron's speech earlier this week on the "modernisation" of public services (note that he's no longer "liberating" the NHS he's "modernising" it) he said:

And new powers for GPs, who can join together in consortia, take control of NHS budgets and directly commission services for their patients. People said there would be no appetite for this. But let me tell you today the enthusiasm of ... over 140 GP-led consortia [who] have now come forward, covering over half the country.

I talk to GPs and I do not hear of much enthusiasm for Lansley's top-down re-organisation of the NHS. However, I hear a lot of other emotions: apprehension, hostility and resentment. But often I hear about resignation to the inevitable. But the facts are there, aren't there?: in December 52 GP pathfinder consortia were appointed covering a quarter of the population, and on Monday this was extended to 140 consortia, as Cameron mentions, covering half of the population of England. Doesn't that show enthusiasm?

No, the opposite. It shows the result of bullying.

I have blogged before about the fears of GPs, and significantly their fear of inheriting PCT debts. It is clear that some PCTs have debts, and that the Department of Health have blamed GPs in part for these debts. After all, if GPs over-refer patients to secondary care, the costs of these "unnecessary" referrals have to be paid by someone: the PCT. These debts are potentially very large, and although they are apparent on the balance sheets of some PCTs, they are hidden on others through loans by other trusts.

GPs are often regarded as being "small businesses" (which is nonsense, because they have a UK-wide contract with the government, they have state-provided pensions and their training is paid for by the state, what other private businesses have these benefits?) and this means that they have some justification in being concerned about being handed a debt in 2013 that was generated by state organisations (PCTs). This was a sticking point in the acceptance of GP commissioning and so the Department came up with a compromise. This is outlined in the 2011/2012 Operating Framework, the rulebook for the NHS from April this year:

5.10 GP consortia will have their own budgets from 2013/14. They will not be responsible for resolving PCT legacy debt that arose prior to 2011/12. PCTs and clusters must ensure that through planning in 2011/12 and 2012/13, all existing legacy issues are dealt with. During this period we expect developingGP consortia to work closely with PCTs to ensure that financial control and balance is maintained to prevent PCT deficits in those years. This will reduce the risk for GP consortia that they could have responsibility for any post 2010/11 PCT deficit unresolved at the point of PCT abolition.

This says two things:

1. The department will write off any debt PCTs accrued until April this year.
2. Any debt PCTs generate after April this year will be passed onto the GP consortia.

PCTs are staffed by professionals and, contrary to the right-wing rhetoric of some commentators, they are not profligate. However, read #2 again: any debt that PCTs generate from April this year will be passed on to GP consortia.

Do you understand now the "enthusiasm" of GP practices to become "pathfinder" consortia? If a GP practice joins a year later then it may inherit a debt generated by someone else. Why would any business want to inherit a debt that they didn't create? The GPs simply want to have their hand on the tiller to try and ensure that the debt they inherit in 2013 is as small as possible.

So while there are a minority of GPs who are keen on GP commissioning (for example, the National Association of Primary Care - the cheerleaders for the previous Conservative administration's GP fundholding programme) it is clear that the real reason for the 140 pathfinders is blatantly bullying in the Operating Framework over inheriting potentially crippling debts. Cameron, as usual, is misleading the public over the "popularity" of his policies.