Changes that will lead to no changes

There is a lot of speculation about how many patients would be covered by each GP consortium. There has been general comments that it is infeasible for a consortium of less than 100,000 patient to do commissioning. England has a population of about 50 million and there are 150 or so PCTs so at the moment, on average each PCT covers about 330,000 people. So it is rather interesting that Healthcare Republic are reporting that the GPC is recommending that GP consortia should "federate" because they say that "consortia covering populations of less than 500,000 will struggle to manage risk". In other words there will be about 100 "federations" compared to the current 150 PCTs.

Can someone now explain why we need to go through the costly changes (that Lansley says will cost £1.7bn, and the Manchester Business School says could cost £3bn) when we will get essentially the same organisational structure?


UPDATE:
The former DoH commissioning chief Mark Britnell has said that GP consortia must be "at least the size of PCTs". While the chair of the RCGP, Professor Steve Field, said last month that just "a few expensive patients" could cause a small consortium to overspend.

Lansley Plays Hardball

So Andrew Lansley knows that the key to getting his denationalisation of the NHS policies accepted is to get GPs on side. They are the key part because they will be in charge of the new rationing system. GPs are not happy. So what does Lansley do? Well he decides to annoy GPs by telling them that their pay will be frozen for two years. Pulse reports that the Department of Health have said that they will not consult the Doctors’ and Dentists’ Review Body over these two years which means that there will be no contact between the GPs' representatives, the GPC, and the Department of Health even to discuss expenses.

It seems as if Lansley is deliberately goading the GPC. GPs argue that they will have to take on additional responsibilities with GP commissioning, and they want incentives to implement Lansley's demand that fewer patients are referred for hospital treatment. (Question: Did Lansley say at the election "vote for me because I want to stop you getting hospital treatment"? No, I thought not. But, I did say that this would happen.)

Their chair, Dr Buckman, is already attacking the government over Lansley's plans to put GP commissioning into the GP contract, which Dr Buckman says is unacceptable. GPs are starting to get vocal about their opposition to Lansley's plans. Yet Lansley is gaily telling everyone that

"GPs across England have fully endorsed his plans"

Yet Pulse say that they have plenty of comments from GPs opposed to the plans, indeed they even report one GP calling for legal action to be taken.

Meanwhile GPs at a meeting in Birmingham have called for a legal challenge to the white paper because of what they claimed was the threat to single-handed practices.
Dr Martin Jones, a GP at the meeting pushing for the move, said: ‘It was recognised that many single-handed or smaller practices are at risk of going under if the white paper goes ahead.’

So how can Lansley say thathe has enthusiastic support when there are still serious concerns over his plans, and when he is deliberately picking a fight with GPs over their pay?

I think that soon Cameron will regret putting such a pig-headed bully in charge of the NHS.

Patient Groups Concerns Over NHS Changes

This a rather excoriating article in Healthcare Republic. It reports the results of a survey by Patient View who surveyed 887 patient groups, representing more than one million patients. They are extremely cynical that Lansley's changes are for the better:

• respondents identified cutbacks as their main fear, despite a pledge to ring-fence the NHS budget
• fear cuts to central monitoring services such as the Audit Commission will lead to a decline in NHS standards
• three quarters do not believe that the government wants to hear their views
• none of the patient groups had been directly consulted by the DoH on the future of the NHS

It is quite clear that the government has the view that it is right and everyone else - regardless of their experience and expertise - is wrong. As Alexandra Wyke, managing director Patient View, says:

‘If you’re going to encourage community groups to get involved in a "Big Society", it might be a good idea to talk to them first’.

Is the GP stance on the White Paper crumbling?

Key to Lansley's privatisation of the NHS is getting GPs on side: if Lansley cannot get their approval the idea will die. The BMA have a long established principle of Keep Our NHS Public and therefore the BMA's General Practitioners Committee (GPC) also hold this view and have provided their opinions through a document called The principles of GP commissioning which includes the statement

"wherever possible, consortia should ensure that NHS providers are the providers of choice."

This has now been challenged by the NHS Confederation are warning that this could be illegal (Healthcare Republic):

Nigel Edwards, NHS Confederation acting chief executive, said GP commissioners should not ‘simply dismiss what non-NHS organisations can offer.’ ‘This principle is doubtful in law and unwise in practice,’ he said.

As I have said before, divide and conquer is the way to achieve your goal, and here is clearly a case of GPs divided.

GPs are slowly forming a view about GP Commissioning

I have always felt that the Ents in the Lord of the Rings were an allegory of the United States; the turning point of the tale was when the powerful Ents decided to give their support to the humans fighting the Orcs.

In Britain, GPs are Ents. Immensely powerful when mobilised, but usually too aloof to take sides. There are now rumblings coming from GPs. Yes, there are some that support Lansley's plans (the NHS Alliance and the National Association of Primary Care are the main cheerleades), but the bulk of GPs are still keeping out of the fray. Now Pulse is reporting that  the GPC is starting to develop a policy towards the White Paper:

"Negotiators are now saying they [GPC] do not support Mr Lansley’s proposal to write commissioning into the GP contract, which they fear would spell an end to the UK-wide contract and substantially weaken their negotiating hand."

The GP Ents are stirring, but will it be enough?

More on GP Commissioning

It is clear that GPs are the lynch pin in Lansley's plans. If he cannot persuade GPs to carry out his plans then the de-nationalisation of the NHS will not occur. Lansley is bullish and arrogant, he believes that when he says "jump" everyone will jump. That is a very foolish attitude to take, since GPs have ruined the careers of better Health Secretaries than him.

So today we hear that Lansley has decided that GPs will be paid £9-10 per patient in management fees for performing commissioning. This will not go down well with GPs. I have heard many GPs saying that the red line is a figure of £12 per patient. Healthcare Republic says:

"A £9-10 fee per patient equates to roughly a third of the management budget PCTs currently receive."

Yet again, there is no supporting evidence that high quality (and safe!) commissioning can be performed for a third of what PCTs are paid. Yet again, Lansley has picked a figure out of the air and is making everything fit that figure.

Understandably GPs are not happy. If they are paid a third of what they need to do the work then they will have to find the rest of the money from somewhere else. And that means cutting into their profits.

Lansley is making the work of GPs far more difficult and this will ultimately result in a worse service for patients. Healthcare Republic reports that the changes in the White Paper are making many GPs think that now is the time to take early retirement:

Essex LMCs chairman Dr Brian Balmer predicted a 'bulge' in retirement as GP commissioning reforms in the White Paper take effect. Dr Balmer said: 'there will be a significant number of GPs who say this is not the kind of general practice they want to do and maybe think now is the right time to go.'

Brian Keeling, chairman of Lincolnshire Local Involvement Network, says 'We have a high number of GPs close to retirement and reforms giving a lot of extra responsibilities to them. It doesn’t take a genius to see that people will see it as a good time to move on' 

This is very concerning. Not only does it mean that the numbers of GPs will fall which will have effects on things like the availability of appointments, but it means that the immense wealth of experience will be lost.

And all of this is avoidable.

UPDATE: More on PCT debts

Pulse reports that it is very likely that GP consortia will have to take on some of the debts of the existing PCTs. This seems rather bizarre since you could argue that the debts have not been caused by the GP practices which are part of the consortia, and so why should they shoulder the financial cost.

The Department of Health said last week it could not guarantee a clean financial slate for consortia when power transfers, heightening fears that GPs could inherit hundreds of millions of pounds worth of debt from cash-strapped trusts. Dr Buckman acknowledged that GP consortia may have to accept responsibility for some modest debts, but warned the policy would ‘not get off the ground’ if they are forced to start from ‘a position of very serious debt’.

Perhaps as an indication of the pressure being applied to Dr Buckman by the Department of Health, he makes a statement that is not unlike Rumsfeld's "known unknowns" comment:

He said: ‘There are several kinds of debt. There’s the debt that inevitably occurs as a result of managing patients. We can argue whether it should or should not transfer to the new consortia. I think if it did transfer it's something we would have to manage and cope with. I don’t have a huge problem with that. Where I do have a problem is where for example the body of GPs opposed things and are now having them visited on us, like Darzi centres and PFI schemes, that the vast majority opposed. There is a whole series of things that were brought in by the previous Government that this Government is now reversing, and we’re going to be saddled with that debt too? I don’t think so.’

Well, I am sure that most GPs are saying: debt is debt, if I did not cause it, why should I be responsible for it? Dr Buckman does, however, point out that unless the Department of Health sorts out the issue GPs will refuse to participate. It is a pity that he's already started the negotiations by conceding so much already.

Cameron's Lies

I leave it to Political Scrap book to put it succinctly: