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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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If nationalising GP commissioning is the answer then the Government is asking the wrong question

Filed Under (GP Commissioning, Health Policy, White Paper) by Paul on 26-07-2010

Since the publication of the White Paper I have outlined some of the problems that come from each of the main architectural themes of the White Paper reforms and hopefully some possible solutions

  1. What is the responsibility of the National in the English NHS?
  2. Who is commissioning health care and how are they doing it?
  3. Who is providing health care and how are they organised?
  4. What are the transactional relationships between commissioners and suppliers and how are they organised?

2 Who is commissioning health care and how are they doing it?

This is the issue at the heart of the Government reforms and this is the policy implementation that unless it remains unchanged will destroy their impact.

The whole stance of the present Government is to diminish the role of the state. Its NHS policy echoes this by attacking NHS bosses as the cause of most problems. It abolishes the state organisations of PCTs and SHAs

It poses against these, for commissioning purposes, the creation of GP led consortia. There are two reasons it argues why GP led consortia will be better than existing state organisations. The first is they will be led by GPs who will understand the relationship between commissioning care and their individual patients much better than an ‘NHS manager’. Second GPs have 60 years experience of working in small business organisations. They think and act and feel like business people. They therefore have an economic incentive that state organisations lack. They understand the economics of investing in something today to make money tomorrow because that is how businesses work.

The Government therefore wants to create new commissioning organisations that are GP led and are businesses. They believe that the combination of these two incentives will make a sufficient transformation in commissioning of NHS health care to be worth the upheaval of the next three years.

But the White Paper undermines that. It says that the GP consortia that will be running most of the commissioning for the NHS will have to become statutory organisations.

This is deeply contradictory.

You do not get rid of the state by making new GP commissioning organisations state organisations.

You do not liberate GPs from the state by nationalising them.

You really don’t.

There are three deep problems with the policy of nationalising GP commissioning.

The first is that GPs have had 60 years of working as small businesses and for all of that time they have worked alongside, and not for, statutory organisations. Over that period generally GPs have not had a high opinion of the way in which statutory organisations have worked. They have looked at the public sector governance that hedges around the leadership of all of these statutory structures. GPs recognise how the room for manoeuvre that leaders need is restricted at every turn. They recognise that it’s not the individual people who run PCTs that cannot make better commissioning decisions. It is the duties and governance laid upon them by the state as statutory organisations.

The strange thing about this policy is that the Government agrees with GPs. They agree that state organisations are not the way to commission – and yet they now appear determined to force GPs into them.

Within 3 days of the white paper being published I was in a meeting that was attended by a junior Government Health Minister. The first question they were asked was “Why isn’t there a nurse on all GP commissioning organisations?”; the second was “Why not a pharmacist?”  and the third “Why not an elected local authority representative?”. The Minister replied, with some agreement, that it would make sense for such voices to be heard on statutory organisations. It had taken just 3 days for a small number of lobbies to get their members onto GP commissioning organisations.

By the time the Bill goes through Parliament there will be a compulsory board of so many members – each of them with the aim of making sure their voice is heard and each of them designed to stop the GP from acting as a small business person, and as a GP. And all of those organisations will see Parliament – the place that passes statutes – as the place to ensure that their voice gets placed on all the commissioning organisations in the country. They will not have to make a case to a local GP. The state will fix it for them.

PCTs are being recreated before our eyes.

The second problem for the policy is that GPs – after 60 years of not working for the state – are not likely to start wanting to work for it now. The White Paper’s answer to that problem is simple. It will make them. Again in a very strange twist of Liberation theology, the White Paper recognises that GPs won’t necessarily want to work for the state but will make them do so. All GPs will be forced to become state commissioners and whilst nearly all of them will pass that task onto just some of their number, these unfortunate few will have no alternative but to become state employees.

What happens if they don’t? What I expect will be happening across the country is that GPs will be setting up their own organisations to develop their commissioning intent. For the White Paper to work will have to nationalise these. What happens if GPs decide not to work for the state? What happens if they continue their experience of the last 60 years and want to work for themselves? How is the power of the state going to conscript GPs to do something they have not wanted to for over half a century?

Liberation through conscription will not work.

Thirdly is a just a small but important point for the Government. In the NHS and in the rest of the public service, the Government have made it clear that they are going to publicly pillory all those public sector workers who earn more than the Prime Minister. (Leaving aside the fact that as a millionaire, in a cabinet of millionaires, his salary is a sort of “tip” paid to him out of public money). So within days of the Government coming to power we saw a list of all ‘NHS bosses working for statutory organisations who are earning more than the PM’. We can expect regular pillorying of such state employees.

Most GPs that run these commissioning consortia will earn more than the PM. That means that the government may well be creating another 2-300 statutory employees who earn more than the PM and who will then be pilloried for earning that money.

If they were working in the private sector – as they would be if this White Paper were not enacted, then they would not be pilloried by the Government for earning that money.

So this is the liberating offer to GP commissioners from the Government.

For the first time in 60 years we are going to nationalise a GP activity across England.

Second we will hedge round your ability to make decisions with a public sector government model that we believe has not worked in the past.

Third we think you dislike this so much that we will make you do it

Fourth we will publicly pillory you for what you earn.

There is no need for this. If the Government understood public service organisations, it could free GPs from the state by suggesting that they form private organisations called Community Interest Companies in order to receive contracts from the State to carry out commissioning duties. Such companies –like Foundation Trusts could not be bought by the private sector, nor could they distribute profits to shareholders.

But they would be liberated from the State and it looks to me that the Government doesn’t really want that.

It’s confused.


8 Responses to “If nationalising GP commissioning is the answer then the Government is asking the wrong question”

  1. Paul – the new world is very confusing for functionaries like me, but your bloggs are helping me to make some sense of what is being proposed by the new government.

    About 10 years ago, I set up and ran a PCG. I know what is being proposed now is intended to be very different, but there do seem to be some similarities, particularly if GP consortia are required to have multi-professional boards as you predict.

    Where I worked there was no shortage of GPs (and other professionals) wanting to serve on the PCG Board. Although the PCG was established under the auspices of a statutory body (ie a sub committee of a Health Authority) I think it felt like a GP-owned organisation. This GP esprit-de-corps was largely lost along the way when PCGs became PCTs.

    A few predications from the PCG experience:

    – there will be endless discussions about what is the ‘right’ size for GP commissioning consortia.
    – there will be a difficult relationship between the consortia and the independent board, as the board tries to balance ‘holding on’ with ‘letting go’.


  2. If ‘PCTs are being recreated before our eyes’ then it gives an alternative migration path to the desired outcome of GP commissioning.First appoint current GP chairs of PBC to the PCT board and give them the authority to direct commissioning . Second replace NEDs with Local Authority reps. Third continue with management reductions in a controlled manner . Fourth move out Public Health and primary care contracting to desired locations.This then creates the desired end point of ‘Liberating the NHS’ and could be achieved by April’11 with the added benefit of continuity during transition and minimum possibility of redundancy followed by re-employment. In the following year the GPs in charge of the new Board could market test commissioning support if so desired .

  3. Hi Paul – I was running a creativity session with some Health and Social Care Commissioners the day after the White Paper was published. One of the ‘Provocative Statements’ made was ‘people should commission their own health care’. The debate and ideas this statement provoked were fascinating – including putting pharmacists centre stage and GPs out of business…

  4. You are correct that this would be a rational path in transitioning from current PCT to GP led PCT, but the Government have a contradiction to work through. They claim that they are liberating GPs from the state and therefore the last thing they can do is arrange a straightforward transition from PCT (i) to GP led PCT (ii). They have claimed that this is a revolution for them, to agree that it isn’t would be too painful, so we will end up with a state run commissioning system but for a litle while will have to pretend that their intention of liberating GP commissioning from the state will be carried through.

    Although I must say that I think the Houses of Parliament will notice and point this out.

  5. Lisa – good to hear from you! I am sure the discussion about self-generated commissioning is an important way forward especially for people with Long Term Conditions who do know a great deal about both their disease and how their live scan be improved. But as the White Paper outlines, the Government have bottled this and have decided that the state will continue to run commissioning – even if led by GPs.

  6. Hi Paul

    Is there to be a new PG Diploma in the Modern History of NHS Re-organisation?

    And, just thought I’d mention why journalists and lawyers are rubbing their hands at the new proposals – 500+ Postcode Lotteries. Oh, the stories that will flow; oh, the potential for judicial reviews.

    I’ve already got a long list of MPs who have raged against postcode lotteries in the past, but I haven’t yet seen the briefing which tells them that the ‘line-to-take’ has changed Have you?


  7. Look,lets just cut to the chase!!Who’s going to be manageing Ophthamology?is it the local consortia the NHS commissioning board,local trust? is there anybody out there who knows the answer?as a volunteer I need to know.

  8. The problem for the NHS, as for most British national organisations, is the complete lack of understanding by successive governments of the importance of stable structures for big edifices. If you keep reFORMing organisations, the processes that take place within them will never settle into an efficient pattern and professionals will never be heard. This is the main reason the Germans are far ahead of us in everything except making rubber bands.

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