The Maynard Doctrine: As the dust settles on the boomerang of reform …

As the dust settles from the White Paper where are we? Apart from the mere issues of detail to be provided in the ten (yes, ten!) consultations in the next few weeks - essential beach reading, with comments requested by October 5th - what is changing?

Goodbye old bureaucracy, hello new bureaucracy
There is a major assault on bureaucracy, with PCTs and SHAs to go. But hold on a minute: aren’t the proposed GP commissioners just PCTs run by GPs?

Moving from 152 PCTs to 500 GP commissioning consortia (GPCCs) is like going back in time to when we had 300 or so too many PCTs.

But the structure and incentives will be better perhaps? Instead of worthies from around the local community, the Boards will now have clinicians on them. Well, GPs anyway.

Hopefully the GPCCs will cut the crap that is inherent in PCT managerial waffle about audit, governance and prioritisation. Perhaps they will be efficient commissioners of care? Let us all pray so, but how will this be evidenced?

Owning the decisions
Furthermore, they will have to own the decisions they make! They will get 150 pieces of pathway and treatment advice from NICE- hopefully costed and affordable.

This they could use in conjunction with QIPP, CQUIN and umpteen other pieces of advice to beat providers up and hold them to account.

Wow! This sounds fun!

But how will principles such as these be translated into practice?

For instance: if GPCs are weak, what will happen? This nice issue is unclear. As is the problem of some GPs potentially saying get stuffed to Citizen Lansley: “I don’t want anything to do with this!”. Presumably over time, this choice can be reflected in their inferior pay?

They may decline to engage in the reform for the genuine reason that they prefer patient care to management. But patient care can be provided by practice nurses with prescribing rights - and so, with appropriate stuffing of mouths with gold, a sufficient number of GPs may just engage with management of £70 billion or so of taxpayers’ money.

And if we fail?
What happens if they fail? The PCT tradition was if you fail, you were “retired” and then given a new job elsewhere in the NHS sometime soon.

If GP commissioners fail, they will go back to patient care - but what about the organisation? Here there is little detail - and much speculation that merger and privatisation may be the order of the day.

Mergers have the obvious trade-off that the fewer GPCCs, the less the competition for patients and choice for those who wish to exercise it.

It is likely that some, maybe many GPCCs will partner private organisations as they establish themselves. They can either re-cycle PCT “expertise” to manage their organisations, and / or hire in the private sector as consultants or partners.

What criteria will be used to define and regulate these contracts? Could the private for-profit organisations or even private not-for-profit organisations take over GPCs if they fail? We await details from Whitehall village with bated breath!

The nice notion of using one set of medically-trained “delinquents” to manage another has been discussed in the literature for over two decades, starting with Maynard, Marinker and Pereira-Gray over 20 years ago in the British Medical Journal (1988) - 1. Perhaps giving GPs the budget will lead to a  “primary care=-led” NHS, whatever that might be.

The evidence base derived from the 1990s experience of GP fundholding and Total Fundholding is poor in quality and quantity. The Tories wanted to believe it was a success, and New Labour was convinced it was a failure. Neither party had evidence in the 1997 general election to support their positions.

So GP fundholding was abolished in 1999 by Labour, to be partially restored by them as practice-based commissioning in 2006 and now implemented comprehensively by the Coalition as compulsory GPCC.

To prevent this wasteful cycle of evidence-free reform, it is hoped that the details of the Coalition’s plans will be convincing and that evaluation will be careful and rigorous.

Without this, be assured that this may merely be another episode of boomerang health policymaking!

References
1. Gray DP, Marinker M, Maynard A. The doctor, the patient, and their contract. BMJ 1986; 292: 1374-1376