GPs will be in charge of commissioning, we’re told. Then we’re told they won’t be because others (including hospitals who have a vested interest) will make the decisions. Are GPs any good at commissioning? They know what the patient in front of them needs, but do they even want to look at tables of numbers and make priorities. Should we stick to the original decision to put GPs in charge of commissioning, should we go with the current alternative to give a seat at the board to everyone, or is it all fatally flawed?
The Conservative party gained the most seats in parliament on a manifesto of No more top-down changes in NHS.“ Of course we should know by now that political promises mean the opposite; what we see here is a top-down change on a grander scale than ever before.
Now that they are in power, the Conservatives are forcing through political ideas that are unworkable. The Health Select committee (with a Conservative chair) has concluded that the whole concept is unworkable after expert upon expert said “well, it might work but . . .” The Health Select Committee asked for a second opinion (public consultation) and it has confirmed their view; the hand-picked pro-government panel concludes “Nope, it is unworkable.”
Not willing to give up a cherished, if unpopular, ideal, the government response has been arrogance of the sort that takes your breath away. “You don’t understand, let me tell you again, louder and slower.” Sycophants from the media and lobbyists from the health industry have chimed in with “Public Sector, and NHS in particular, doesn’t like change.” This is getting exciting; you couldn’t make it up! But the facts show that health care has changed: Keyhole surgery, superglue instead of stitches, cancer treatments, genetic profiling, PACS (use of IT to deliver scan images and X-rays), telemedicine and telemonitoring, day cases instead of admissions, the list goes on and on. Public sector, and NHS in particular, doesn’t like badly thought through change with disastrous consequences. As John Kotter says “a 5-year old child could tell you that it won’t work. Trouble is, there’s never a 5-year old child in the board room when you need one”.
I have to commend the government and the Secretary of State for Health; it is a strength to do a U-turn if the idea is rubbish. But it’s better still to do a quick impact analysis before announcing a policy, and get it roughly right thus avoiding wasting so much time. Not to worry, previous governments have a poor track record too; Tony Blair was fond of forcing things through anyway, and Margaret Thatcher announced “a great victory” every time she did a U-turn and even gave a speech about “the Lady’s not for turning” (immediately before giving away massive concessions to Brussels).
So what do we expect to happen next?
To be fair, that’s anybody’s guess. GPs, especially GP partners, do make the best decisions because they have to live with the long-term consequences; they will still be around in 15 years when a person they didn’t treat develops some awful condition and needs 24 hour care. Salaried GPs average 2 years in a single job and are less inclined to worry about the future, or the costs of care, and more inclined to follow the guidelines (“refer everyone for further tests”). GP partners in a GP Commissioning Group might keep health care costs low, but only if they are interested.
GP partners became GPs in order to deliver the very best health care to each individual patient. They didn’t join up to look at numbers and forecast trends. They may be good at it, but it doesn’t interest them (and most are actually terrible at it). So they will delegate to managers, and the managers will make decisions and think that it is their right to play god with health care, and nothing will change. There are so many ways we could have done this to achieve better results.
If Primary Care Trusts (PCTs – the organisations that decide how many of each type of treatment will be needed, so hospitals staff up and buy equipment) were made accountable to a panel of GP partners then PCTs would be a lot better at their job. This doesn’t mean the GPs have management meetings every week, it means the GPs can say “you did a bad thing there, you’re fired” or “by this time next year we want more of this”, and then go back to their day job of saving NHS and UK taxpayer £billions.
This isn’t the only way. An alternative is to give the task of commissioning health care to the Local Authority. The Local Authority already commissions just about every other service for health and well-being (education, housing, crisis teams, social care, looked-after children, elderly care, etc), and has robust frameworks which NHS lacks. The Local Authority is also accountable to the local population, who are much happier to say (through their elected representatives) “you aren’t doing this right, improve or you are sacked.“
In contrast NHS in both its current, and future, form isn’t accountable to anybody; most patient facing staff and the front-line staff who support them are fully committed to delivering the best service, but there are people with other incentives, driven by a tick-box and target culture, who tend to treat the patient as a bit of a nuisance. Of course NHS needs more managers to make it run smoothly (the numbers bear this out, contrary to media propaganda). But mostly NHS needs to be accountable to somebody, anybody! Top down changes cause a lot of disruption and cause good people to leave, but on current information these top-down changes won’t improve anything. A little more accountability might make a big difference!