Feature

Making it up as they go along?

Do the government’s plans to expand GP fundholding mark the start of a new, consumer-friendly NHS — or the abandonment of progress towards accountability and equity in health care? Wendy Moore canvasses opinion

According to health service folklore, it is possible to chart the shifting balance of power between hospital consultants and family doctors by tracing the Christmas mail. Back in pre-NHS days, the consultants, anxious for business, sent Christmas cards to GPs. Then, as consultants gained the upper hand, GPs sent the cards. Now the postal flow is shifting again and GPs’ desks have recently been covered with seasonal greetings from consultants touting for business.

Family doctors are the new top dogs in the NHS. Once the fiercest opponents of the government’s health reforms, they are being fêted with flattery and financial inducements to become the leading power-brokers of the future health service. Nearly 40 per cent of GPs have already joined the government’s fundholding scheme — giving them limited power to buy certain services direct from hospitals. The latest plans to extend fundholding (see below) suggest the government intends eventually to put GPs in charge of all healthcare purchasing, leaving health authorities a diminished and difficult supervisory role.

If all GPs become fundholders, theoretically that should solve the problem of the two-tier service which has fast developed between patients of fundholding and non-fundholding doctors. But if two tiers have been the main concern of critics so far, it is possible they ain’t seen nothing yet.

Some health service experts predict total chaos ahead. Instead of two tiers there will be multi-tiers, with vast variations in standards and nobody held to account for bad practice or corruption. So far, fundholding has been led by entrepreneurial GPs in large, well-organised, well-supported practices with generous budgets. But concerns now centre on less able GPs — from the single-handed inner city doctor struggling against the odds to the downright negligent.

Even the most enthusiastic advocates of fundholding admit there is a problem. Dr Stephen Henry, former chair of the National Association of Fundholding Practices, told a recent conference that health authorities do not possess sufficient powers to bring poor practices up to acceptable levels of care, ‘let alone to be robust enough to fundhold’. He said: ‘Unless this is done, the gap between the two types of practices widens inexorably and creates a real two-tier service.’

Rabbi Julia Neuberger, chair of a London community health services trust, also voiced alarm about ‘rotten apples’ in a recent article in the Health Service Journal. ‘Bright, inspired and dedicated GPs can make fundholding work wonderfully for their patients,’ she said. ‘But equally some GPs will make an awful mess of it due to failure of comprehension and lack of the right kind of energy.’

The new health authorities — the old HAs are to merge with family health services authorities in 1996 — will be too big and remote to know what is going wrong, she says.

A series of ‘mini-crises’ will be the first obvious sign, predicts Ron Singer, media officer of the National Association of Commissioning GPs (NACGP), which represents doctors who have rejected fundholding in favour of working jointly with HAs to purchase services. GPs working alone — 40 per cent where he works in north London — will find it hard to cope with fundholding. HAs will be unable to make GPs work to set standards or to long-term health strategies. ‘I see practices going bust or making errors,’ he says.

He suggests, however, that a re-elected Conservative government would make fundholding compulsory and lay down national standards with which GPs would have to comply. He sees hospital trusts being destabilised by GPs’ changing whims. And with tighter restrictions on public spending, GPs will be forced to ration care among patients or encourage those with private insurance to use it to jump the queue.

Geof Rayner, chair of the pressure group Public Health Alliance, not only agrees with the chaos scenario, he sees it as a deliberate policy. ‘The agenda is fragmentation,’ he says. ‘The abiding theme of the Conservatives is to introduce fragmentation into everything.’ Forcing purchasing down to the lowest possible level — and introducing local pay for NHS staff — is all part of a grand plan to steer the health service towards a full-blown market.

He points out that fundholders have been given powerful financial inducements to join up. As well as £35,000 for administrative costs, they receive generous purchasing budgets giving them more spending power per patient than HAs. They can channel savings into improving their practices, including upgrading premises which they can later sell at a profit.

Hertfordshire fundholders have accumulated a total £3m savings since the scheme started four years ago — money which has been topsliced from the general health service budget. This year, facing an overspend, they are refusing to use their own windfall.

Geof Rayner warns that the system could lead to abuse, especially when, inevitably, budgets become tighter. Unscrupulous GPs might start selecting the ‘cheapest patients’ for their lists — rejecting elderly people or the long-term sick. Sanctions to deal with negligent GPs are already inadequate, he argues, but even if HAs had the powers to do something about such abuses they would not know it was going on.

Another subscriber to the chaos theory is Andrew Wall, a former NHS manager and now senior fellow at Birmingham University’s Health Services Management Centre (HMSC). He thinks the government aims to turn all purchasing over to GPs, leaving HAs with responsibility for broad strategy but few powers to ensure it is implemented. Many believe that will lead to big job cuts in already demoralised HAs, which are likely to cover ever larger areas, becoming ever more remote.

‘The great danger is commissioning authorities are seen as power-crazy, non-clinical people, or public health people, telling the rest of the NHS how to do their job,’ he says.

In the process, public health needs will be neglected or disregarded altogether. HAs will resemble the area health authorities of the 1970s — forever ‘reading books and having meetings’. Significantly, areas were abolished in 1982.

Certainly HAs will have little power to influence varying standards among GPs. Recently arrived from the west country, Andrew Wall has been shocked by the poor quality of some West Midlands practices, like those where patients queue outside for appointments.

He is not convinced the government has a grand vision, however, agreeing with his colleague, HMSC director Professor Chris Ham, that ministers are ‘making it up as they go along’. But if the Conservatives win the next election the ‘inescapable logic’, says Mr Wall, would be to float trusts as private entities, retaining only the purchasing side in the public sector. GPs, already independent contractors, might also be given more freedom and less accountability.

Fundholders themselves have been at pains to argue that they are more accountable than anyone else in the health service. They currently provide monthly reports and annual accounts to FHSAs and, under new plans announced by ministers in December, they will have to provide HAs with annual practice plans, performance reports and notice of any major shifts in purchasing intentions.

Dr Rhidian Morris, chair of the National Association of Fundholding Practices, says: ‘We are directly accountable every time someone walks into the surgery. We have created a more patient-sensitive system. HAs cannot do that because they are not directly accountable to patients.’

But Toby Harris, director of the Association of Community Health Councils for England and Wales, points out that the typical doctor/patient relationship is far from equal. Most patients are in ‘awe’ of their GPs. Real consultation means a formalised statutory process involving patients’ representative bodies. Without that, he too predicts an ‘anarchic internal market’, with differing standards of GPs.

One answer, according to public health director Dr Steve Watkins, who is president of the Medical Practitioners’ Union, might be ‘total purchasing’, an initiative being piloted in four areas and set to expand under the new plans, where GPs are given a budget to buy all services for their patients.

Like many experts initially cynical about the reforms, he is now convinced of the benefits of devolving purchasing — or commissioning — to local level, possibly to elected neighbourhood committees rather than GPs. Total purchasing could be one solution, provided it offers real accountability and ensures HAs have powers to map out public health strategies.

Dr Quentin Shaw, vice-chair of the NACGP, also believes there is merit in total purchasing — which is very similar to the commissioning groups some GPs have set up with HAs. Himself a member of a 44-strong commissioning group in Telford, he sees many benefits in GPs and HAs working closely together to plan and commission care.

Like others who have welcomed the turning tide in the Christmas post, he hopes a future Labour government — at present committed to abolishing fundholding — does not throw the local commissioning baby out with the fundholding bathwater.