Dear patient – the letter every GP should be sending

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I have been talking to GPs — lots of GPs — who are terrified of the upcoming NHS reforms.

Almost to a person they know these reforms cannot deliver a better NHS. When hospital doctors are added into the loop the consensus is overwhelming — that this is an outright disaster for patient care in England waiting to happen.

And they’re frightened to stand up and say so — because they know they could lose their livelihoods if they do.

Well, they may be frightened, but based on what they’re saying this is the letter I think every GP in the UK should be sending to their patients — every word of which is, I think correct:

“Dear Patient

We thought we should write to you about the health reforms that the government is proposing for the National Health Service. This is especially important as you may well have seen that the government is planning a major role for GPs — that’s us in the new structure of the NHS.

The government is basically planning three major reforms to the NHS. The first is that Primary Care Trusts that have organised the use of NHS funds at a local level for the last few years are to be abolished. They will be replaced by what are being called GP Commissioning Groups.

Secondly, the way in which secondary care in the NHS is provided is to be changed significantly. Instead of GPs referring you to another NHS institution if you need care that a GP cannot provide we will now have to refer you to the person who is willing to provide the service you need at the lowest possible price, irrespective of quality or what you might wish.

Thirdly, this will mean that our local hospitals might well very soon not provide the whole range of services that they do now, and that care will instead be spread over a range of different providers over a range of sites, many of which might well be further away than at present.

The purpose of this letter is not to say whether these changes are right or wrong. We are not expressing an opinion on that, and it would in any event be pointless of us to do so. We have not been asked whether we wish to undertake the new tasks the government is giving us. Nor has anyone checked we have the suitable skills and qualifications to undertake these activities. We have simply been told they are going to happen, and we are going to do them. Our job is, therefore, to get on with dealing with the issues that arise from them, but we think you need to know what the implications of the changes are.

We think there are three vital consequences of these changes that you should know about. The first is that the amount of money the government is giving to the NHS is going to fall in real terms very significantly. For example, the amount of money given to us in our new role as GP Commissioners will be much less than the payments provided in the past to run the Primary Care Trusts that undertook similar work. At present no one has told us how costs can be cut to the extent the government wants. And no one has also told us how we are to be paid to do the work of GP Commissioners.

This last point is very important. If we, as your GPs are working to run the administration of the NHS we’ll be taken away from our existing full time roles as GPs, where there is already no slack in our time to take on extra tasks. We are really worried that this will mean we’ll spend less time seeing you, our patients unless we are given funds to employ more doctors - but no one has, as yet, seemed to think about this issue. As a result we’re really worried that you may not get as good a service in the future as you have enjoyed from us to date if these changes do happen.

Second, we are also really worried about the changes that are proposed in the rules on who we may refer you to if we think you need specialist care. At present we do not have to take cost into account when referring you. There are two reasons for this. First, we’re not responsible for accounting for that cost, the Primary Care Trust is. That means we refer based purely on your clinical need and nothing else. Secondly, all people supplying a service in the NHS right now (for example, a particular operation) have to charge the same price for it. This means we can refer you to who we think is the best provider of this operation and price is never an issue. Alternatively, you can choose which NHS provider you want to go, and again price is not an issue.

This will change under the government’s new rules. As GP Commissioners we will know the cost of patient care, and (let’s be honest) that will also mean we will be responsible under the new rules for rationing that care. We do mean rationing too, because there is no more money available. That will give us terrible problems when we know there Is no money left and yet we also know a patient needs vital and expensive treatment. We have always wanted what’s best for you. The new system creates a direct conflict for us. We will have to serve you and a cost cutting government at the same time — and we’re not sure how we can do that.

Perhaps more worrying still, the new rules mean that in future we will have to refer you to whoever is the cheapest provider of a service. They may not be local. And they may not be the best provider, in our opinion. They may also not be as quick as we’d like. But price will rule. We will not, legally, have a choice, and nor will you. The cheapest provider will get the work.

That’s bad for you. And it will be bad for local hospitals. They work well now because they provide a whole range of services across all medical disciplines and, as importantly, whether the work they take on is routine or very difficult. At present it is the routine and more straightforward work that hospitals do — that is relatively well paid — that helps provide the funds to pay for complex care for those who are very sick. And it’s also the current fixed prices paid for that relatively easy work that helps hospitals train the next generation of doctors who need the experience that work provides. We fear that training will end under the new system because no one is required to pay for it in the new NHS in the prices they’ll be offering for operations and other procedures.

But worse still, we think that this will mean private providers will bid at low cost for all the easy operations and procedures but complex, difficult procedures will be left with the local hospitals. The trouble is that those local hospitals will, unless they also undertake the regular routine operations and procedures, not have the money or skilled people they need to provide the services really sick people, who are often the elderly, really need. And as a result we’re really worried the sickest people we see might really lose out as a result of these changes.

Of course we should add that some say that things will not work out the way we’ve described. We hope they’re right. We hope there will be enough money to go round. We hope that care will improve. We hope you will get a better service than that we’ve really tried to provide to date.

Equally, we have to say that to date no one has told us how that will happen, and we think we have a duty to share that concern with you now, so you know the problems we will be facing in meeting your demand for NHS services in the future.

Best regards

Drs X, Y and Z

Your GPs”

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