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Editor’s blog Tuesday 14 September 2010: Lansley's White Paper - timeline and vagueness criticised by RCGP; others defend it

The Charge Of The Light Brigade: cavalry call for strategic sharpening-up and tactical slowdown
GPs seem to have woken up to the fact that Health Secretary Andrew 'The Liberator' Lansley's plans for them to charge the heavy artillery of NHS vested interests could involve their liberation from high levels of trust and popularity they apparently presently enjoy.

Well spotted, people.

The field of battle for this modern-day Charge Of The Light Brigade is not the Crimea.

Instead, the battleground is the three Cs of choice, competition and commissioning. And the Royal College of GPs has, through consultation with its members, found "major concerns" (which is probably slightly better than Lord Cardigan).

The framework for the RCGP's response pulls no punches about its concerns, which it lists as follows:
"There were many queries about the lack of detail of how the reforms might impact on services and the workload for practices, and a significant numbers of comments on the risks of these reforms to the NHS in England, as follows:
- Rather than efficiency savings, both financial and human resources would be diverted away from clinical care and quality improvement into issues around commissioning and resource management. The extent and speed of the reforms risk destabilising both the interpersonal relationships and economic basis of local health economies at primary and secondary care level
- Local diversification will be likely to increase rather than reduce health inequalities.
- GPs will be seen as the purse-holders: this could reduce public trust and decrease their ability to advocate for patients, and they will be blamed for failures and cuts in services
- Many GPs currently lack time, skills and capacity for commissioning – this will need addressing urgently.
- The reforms open a door to increased involvement of the for-profit private sector in the NHS, and tax payers’ money will be diverted into private companies and their shareholders. This could be seen as the break-up of the NHS, with some private companies ready to take over the provision of services.
- The reforms take the health service in England further away from the health services in the other UK countries, although the training for GPs remains the same".

The RCGP Council's debate on their members' comments resulted in the following statement in the document:
"Some of our members are not convinced that the scale of the changes proposed is justifiable, especially in the context of cost reductions. They are concerned that the proposed scale, pace and cost of change will prove disruptive; and that the proposed reforms may not achieve the stated aims because they will divert effort, costs and human resources into complex commissioning and local decision making.

"Some members are also concerned that GPs will be held responsible for shortcomings in services, and that this will disrupt public trust in the crucial doctor-patient relationship which underpins effective uptake of services and clinical interventions. Fundamental to those members’ concerns was that the ability of the NHS to provide a high quality service should not be jeopardised by irreversible changes to the infrastructure of the NHS, including imperatives to offer choice and an increased dependency on private providers.

"Other members, particularly at the start of their careers, welcomed the opportunities for increased potential to influence services to patients and the wider community".

This is pretty bold politics from the RCGP. The document strives to be even-handed, noting also that their members had highlighted the various opportunities for general practice to achieve "greater influence by GPs on patient care and health services, through direct leadership and greater input to the Department of Health.

The RCGP's senior officers emphasised "the opportunity to work more closely with local government, joining up with social care and public health; delivering even better education and training for nurses and for GPs – including extending the period of GP training to deliver GPs with appropriate knowledge and skills; and potential for better workforce planning. Council emphasised real opportunities to work more closely with patients, and to develop stronger links with colleagues in specialist practice".

Was there a man dismayed?
You bet there was.

Health Secretary Andrew Lansley is likely to be livid that his liberation theology has not convinced many of the medical priesthood upon whom it relies to stand a chance of success.

The call for a slowdown in pace will really not suit Liberatin' Lansley. After the media bounce forcing the release of his White Paper, the last thing his authority and confidence needed was a challenge from a respectable medical body to the timescale.

The DH have been asked for a comment from the Health Secretary on the RCGP framework response, which will appear here on receipt -  if there is one.

UPDATE: A DH spokesperson commented, The Pulse article (referring to this media coverage) is not an accurate reflection of the consultation. In reality, the report reflects the feedback we've had from engagement events across the country - most GPs are enthusiastic about the opportunities offered by the White Paper, but many are also apprehensive. For this reason, we will ensure that detailed implementation issues are tackled during the course of transition, and we look forward to the RCGPs (sic) full response to the White Paper consultations".

It would be fair to say that Labour leadership candidiate and Shadow Health Secretary Andy Burnham is not wholly distraught about this fresh challenge to Liberatin' Lansley's plans.

Burnham's statement today says, "this summer has seen a growing chorus of protest over the Government's NHS reform plans, but today we are seeing a major setback. Mr Lansley's plans don't even have the support of GPs - the very people he wants to implement them. He talks about listening to GPs - everyone who cares about the NHS now wants him to do just that and put his plans on hold.

"Once again, GPs are telling the Government that they don’t want these reforms.  GPs are saying that the White Paper will divert resources from patient care, create a postcode lottery, and represent the break-up of the NHS. GPs don’t want to be the purse-holders, they want to be advocates for their patients.  Mr Lansley must listen to them and give up his plans to dismantle the NHS".

Others don't want to hit the brakes
Dr Michael Dixon, chair of long-time GP commissioning supporters NHS Alliance, takes a broader-church and more ecumenical view of the RCGP's comments.

Dixon told Health Policy Insight, "the White Paper's timescales are ambitious, but I think achievable in many areas, especially where PCTs and GP practice-based commissioners (who may form the basis of the future commissioning consortia) have a supportive relationship.

"I think the problems wlll be in areas where the two are not talking; where PCTs are running a less-tight ship than they might and where there are deficits, meaning those are areas at risk of many redundancies where new commissioning consortia may not want to take on ex-PCT people.

"There will be areas in 2013 where the new independent commissioning board will say 'you're not ready for statutory responsibility - but if we tell people in the NHS to slow down, not a lot happens. So we have to set timescales.

"I agree that the timescale is ambitious, but I think it's do-able by 2013 for most. Where it's not, we need contingency plans, but it's too early to talk about those at the moment. Slower-progress areas will be balanced by areas which are ahead of schedule, where GP consortia will hold hard budgets way ahead of 2013.

"I'm very supportive of the RCGP stance, and have sympathy with the real fears their report expresses. Any big change involves risks as well as opportunities.

"But I don't agree that the White Paper represents a threat of privatisation of general practice. I think that if GPs turn their backs on this reform, and refuse to lead and responsibility for local health and local commissioning, the government will say 'OK, we'll get someone else to do the health economics' - and go to the private sector, People who warn of a risk of privatisation from commissioning may be right; but the risk of privatisation from GPs not taking this on is far greater.

"On the RCGP's points about services, inequalities and change, front-line people are and always were best to to do this: it's sad that's only been recognised late in the day, but good that we got there in the end. Over the past 14 years, we've staggered from GP fundholding to commissioning; from PCGs to PCTs - this seems like a natural end point.

Dixon concludes, "I understand the fears, but I urge all GPs move forwards as eagerly and fast as possible. This is an opportunity of a lifetime, and yes, we need to amass experience and knowhow as fast as possible. We need to develop many skills; to enable and learn leadership. None of this should make us fearful, as we are the best group to do commissioning - and we shouldn't over-estimate how well it's been done in the past by others".

Defenders of the GP commissioning faith
A similar note is struck by Dr James Kingsland, chair of the National Association of Primary Care, who said, “that seems quite a negative outlook. It’s cautious, understandably, but I’m concerned (with the greatest of respect to the College and its network).

“My sense is that the government is saying that it’s depending on general practice and its demand management to help the NHS continue as a free-at-point-of-use system. They’re looking to general practice for leadership, and will resource us to deliver the system first described in 1948 where the generalist is gatekeeper, manager, navigator. For the government to be saying that, to me, is absolutely fantastic.

“With the opportunity come risks and accountability. There could also be lots of rewards - not for GPs, but for patients looking to GPs to extend their care, and keep them out of hospital.

“We can tend to focus on the macro- aspects of commissioning (which this RCGP document seems to have done), but we need to think about the micro-level commissioning decisions we can all make.

“This is a fantastic opportunity for general practice. I and others lobbied long and hard to have general practice and list-based practice as the cornerstone of the NHS. These reforms all build from that position, including responsibility for committing the public purse. I think general practice is up to it. The issues about upskilling, extending care, multidisciplinary teams are all real – and they excite me.

“There wil be macro-commissioning by a smaller niche group of interested, skilled clinicians: all well and good. For most GPs, commissioning is going to be about 8,300 practices and every GP aligning clinical and financial responsibility. That  makes me feel very positive.

“I fully respect what the RCGP report is saying and understand the concerns. But the government is saying ‘we really want general practice to succeed’. Never in my time as a GP have I found government so keen to ensure we succeed and to give us the tools.

“Time tell who’s right, but I’ve been around long enough not to be a naïve supporter of policy. This is potentially the best time for peneral practice since I first became a partner back in in 1989.

“Of course we need colleagues to investigate risks, and mitigate against them; we have to air concerns and seek solutions -  but if we then say those concerns mean we do not progress with something that’s even called GP commissioning, then I’d really worry


Kingsland concluded, “If don’t grasp this with both hands and make it work, that will say a lot about the future of general practice”.