Reforms are not the medicine the doctor ordered

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In the opinion of Dr. Kailash Chand, former member of the British Medical Association council, “this proposed bill is the biggest challenge to core NHS values.” The coalition government’s white paper aims to radically alter the organisation and management of the NHS, and shift control from the state and primary care trusts (PCTs) to GP consortia, local authorities and private companies.

Under the guise of ‘public sector reform’, the coalition looks set to continue the trend set by New Labour, removing national controls in favour of local controls and greater autonomy for patients and health professionals.

But without any formal piloting, these reforms simply will not scratch the surface of current shortcomings in patient care – instead, they will spell the start of a health service economy.

The fact is that GPs will not be able to manage the allocation of financial resources worth over £80 billion; they haven’t been trained in resource management, nor do they have the time or experience. The only option available to many consortia would be to buy in help from private companies, with the amount of money spent on good organisation being up to the individual GP practice.

The phasing out of PCTs by 2013 will move responsibility for decisions affecting the entire NHS budget from national control to control at a more local level, and it is very difficult to see how this local control could be sustainable without inequalities in NHS care. Inevitably, it would lead to exactly the sort of ‘postcode lottery’ situation that NICE was set up in order to avoid, as some consortia would provide services that others would not.

Furthermore, GPs face a fundamental conflict of interest in that they are both providers and purchasers. Should they put the needs of their patients first, or the needs of their consortium first? Are they healthcare providers, or are they accountants?

The NHS being a system within which there are finite resources and, effectively, infinite demand, the new proposals make it a clear economic advantage for a GP to not treat their patients.

Because of their new role, GPs may feel that they have to refer a patient to a cheaper provider, or prescribe a cheaper treatment, to cut costs – and to add extra pressure, the White Paper has made it very clear that “there will be no bailouts for organisations which overspend public budgets.”

What is unclear, in fact, is what would happen to the patients attending a GP practice, were its consortia to become bankrupt. How would their care be provided for?

The lack of piloting of Lansley’s proposals has thus resulted in a system that firstly lacks a safety net, and secondly has potential problems within which the old, vulnerable and those unable to travel would be most affected.

The move towards a more competitive, market-led NHS is unmistakable. Under these reforms, patients will be given the right to register with any GP, regardless of catchment area, and to choose between consultant-led teams for elective care.

This would disadvantage patients who were not able to travel far from home, or who were unaware of a GP or hospital practice providing a better service than their current one.

But more than that, this is a system designed to make GPs and hospital trusts compete for patients. It is based around the traditional, laissez-faire idea that competition breeds excellence and market forces make everything more efficient. The assumption here is that economic excellence is the only kind of excellence worth having.

This approach could well result in a greater emphasis on saving money and providing cheaper NHS services. However, the possibilities of corners being cut and patient care being compromised are too real to skim over lightly.

Angela Sheard

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