GPs can’t do this – and shouldn’t do this – and we should not tolerate it

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Andrew Lansley will announce a plan to save £1 billion in the NHS today – by cutting what he calls central bureaucracy.

The plan as I understand it is as follows. First, the primary care trusts that currently coordinate GP services will be abolished. Their job will go to GPs – who will coordinate themselves.

Second, strategic health authorities will go.

Third, all hospitals will be encouraged to become not for profit companies.

Fourth, and maybe incidentally, some organisations such as the Food Standards Agency will be abolished – assisting release of an epidemic of obesity.

I have some interest in this issue and should declare an interest: my wife is a part time GP.

So let’s first of all applaud some good news in this. GPs will no longer have differential contracts – some on something called GMS and some on another contract called PMS, that latter paying £10,000 pa more than the former, for no difference in services. That was always illogical.

Second, GPs will not longer be allowed to own pharmacies. That’s very good news indeed. Thee pharmacies have been abused by some GPs for personal gain at cost to the NHS. It is very welcome that this conflict of interest will go. But some practices will be £30,000 a year worse off as a result.

Third, GPs will no longer be able to set up service companies they own to provide minor operations to the NHS, undercutting hospitals, creaming off profit and (I think) sometimes prejudicing patient care on the way. I am very pleased that this change is happening: it always created a conflict of interest in patient care that had to be abolished. But of course many GPs will be worse off as a result.

I’d add, my family is unaffected by these welcome changes. My wife has left practices because of concerns about prescribing and independent treatment centres. She now works in a GMS practice that does neither. There’s no personal gripe on income going here.

That’s the end of the good news. From here on in there is only potential disaster to relate.

First, these cuts are almost bound to mean more than 20,000 job losses. These people will simply add to the register of the unemployed – even if some made redundant get new work others will be deprived it as a consequence. But on this occasion that’s not the biggest deal (amazingly). The big deal is the assault this represent on the NHS – for it is nothing else.

The claim is that GPs will now direct some £80 billion of funds to hospitals through commissioning groups they must set up and manage by next April. let me assure you – GPs are quite unable to fulfil this task. I have met a lot of GPs. I doubt some can run their own personal bank accounts – and the lack of information most have on running their practices is staggering. Nor do they need much: they have fixed income (near enough) that they expend. To suggest that GPs have the skills to manage budgets of the size suggested is ludicrous: they don’t, they don’t have the training to do so, and what is more they don’t have the inclination to do so. That is, after all, why they became GPs. That is not something that happens by accident: it takes years of hard work where conscious decisions to reject easier and much, much less stressful ways to make a living (accountancy, law, the City, public health physician, being a politician) are rejected along the way.

They also have no time to do so. Good GPs (and many are: not all – but many) work very hard. A typical day will include 32 to 36 patient appointments – at over 10 minutes each on average (especially if a woman GP – and more than 50% of GPs are women now – because they tend to see women who need more time). That’s 6 hours of patient contact time. Then there are at least 8 patient phone calls a day – another 40 minutes or more. Plus three visits, taking up to 90 minutes of time. That’s over eight hours before the GP then has to deal with all the correspondence arising from that lot, reviewing results and actioning follow up, dealing with training (of junior doctors, which most GPs do), staff management, practice management, NHS interaction e.g. with the PCT and other parts of the NHS, personal training and reading needed to keep up to date, and even occasionally getting time for sandwich. For a good GP that’s at least an eleven hour day, on average, to then come home and worry most of the night about the patient they did not send in to hospital and they now wish they had done – who they will call in the morning just to make sure “they’re all right” – but which is actually to make sure they’re still alive – and I promise you, they all do this.

Sure they’re well paid. But make no pretence – before 2004 when the contract changed you could not get new GPs for love nor money. Even now a considerable number of new GPs are foreign graduates because it is incredibly hard to get UK medics to manage the enormous uncertainty which is the normal daily fare of the GP.

To suggest that there is time in this day to manage £80 billion of budget is ludicrous. It is not possible. My wife has been asked to be on one of the new commissioning boards. There will, I gather, be six doctors on it. She has been allocated a maximum of 4 hours a month to do this job, if she wants it. So that’s (after holiday allowance) 40 or so hours a year – and just 240 hours for all the GP’s involved. That’s about 1.5 months a year to allocate the budget for a large area. So let’s not pretend this is going to be possible. It isn’t. And if no pay is going to be allocated unsurprisingly GP services will come first. Of course. That’s the bit she can be personally sued for if she gets it wrong.

Anyone with any sense and the time to ask can find this out. I presume Andrew Lansley. He must know this cannot work.

So what’s really happening? I suggest it is this. He is setting up a system that is intended to fail: a system which will result in outsourced contracts to the private sector in two years, which will contract with NHS hospitals that will by then be limited companies and ripe for takeover within another two or three years so that by 2016 those hospitals will be up for sale at knock down prices – “essential to clear the deficit” will be the argument.

And what will happen to NHS services? Broken legs, routine operation and the like will do just fine. The private sector can deal with such certainties, drop them into a spreadsheet and allocate funds to match. But what of the 30% of all people who present to the NHS, even with long term chronic illness, who never get a diagnosis because they fit into no known box - simply because medical knowledge has not yet found one? What for them?

Or the depressed?

And the old (often called the “crumblies” I note by those doctors most keen on the market)?

And the lost and the lonely for whom the GP is the only advocate – but who now cannot advocate for fear of running out of budget?

What of the conflict of interest every GP will face – and be sued for – when the patient claims they were not referred because the GP was seeking to preserve the NHS budget by not doing so – and as such had compromised medical judgement? What then for the risk that GPs face – already enormous and crushing for many? This is the treason for the difference between primary and secondary care as I see it.

I could quietly weep at the injustice of all this – and the callousness of it – and the blatant lies that will claim this is about efficiency when it is about private gain for Lansley’s friends.

But I don’t do quiet weeping. I get angry. And I’m very angry indeed. For the people of the UK, and the fact that yet again public good is going to be captured for private gain. Which sickens me.