Feature

Plenty of interests in PCGs

Steve Iliffe analyses the complex politics which will dominate the early life of primary care groups

In 31 March 1999, fundholders will slam their ledgers shut for the last time. The next day they will open new ones, as part of larger consortia of general practices called Primary Care Groups, operating as sub-committees of the local health authority. No longer purchasing specialist care for their patients, GPs in the new PCGs will be under pressure to keep within prescribing budgets, improve clinical practice by collective adherence to evidence-based practice, and advise on commissioning hospital care for populations of around 100,000 people. These groups will be led by 12-strong boards, representing GPs, practice nurses, community nurses, social services, the HA and the public. They will work to local plans for health services determined by HAs and local government.

This is a major change in how the NHS works, the second nationwide re-organisation in a decade, and at first sight a victory for those who advocated planning (locality commissioning, in the jargon) against market forces, represented by fundholding. It should not be underestimated as a reaction to the debacle of fundholding, but equally its limitations should not be ignored. Fundholding involved half the GPs in Britain, and some were still signing up to it as Major’s government lost its grip on office. It also involved the entire HA structure across Britain, which remains largely intact from the previous administration. Strong forces are working to emphasise continuity rather than change, with HAs and fundholders colluding to transfer power and resources into the new PCG structure so that the more things change, the more they stay the same.

The government has little choice but to compromise, since the medical profession is now to the right of the government and no longer the brave defender of a form of social provision that suited its members well.

A conflict with the British Medical Association is not on the agenda, given New Labour’s need to champion the NHS and keep the middle ground content. On the other hand the BMA has no doubts about its longstanding belief that what is good for doctors is good for the public, and will defend its members’ interests robustly.

Countervailing pressure against the forces of continuity may be hard to generate, but is exactly what is needed as PCGs develop.

Doctors will dominate PCGs from the outset. In almost all areas GPs voted for a majority of places (seven) on the PCGs, and also for the automatic right to the powerful post of board chair. Nurses were left with two seats, one for practice nurses and the other for district nurses and health visitors. Social services take one seat, the HA one, and the public one. The message from doctors to other professionals, and to the community itself, about who will be in charge of the new, reformed health service could not be clearer.

This dominance is reinforced by the involvement of Local Medical Committees in running PCGs. LMCs are the democratic bodies representing GPs at HA level. Nominally independent, they are actually controlled (‘serviced’) by the BMA apparatus, whose full-time officials have seen the PCGs as a route into local power. Doctors’ rivalry with NHS managers generates enthusiasm for this opportunity to turn the tables on HAs by infiltrating and dominating their lower echelons. There is a danger here – not only does the medical profession profess to speak for the public interest but its political machine is all too ready to speak for the profession. The prospect of PCGs evolving into budget-holding trusts, purchasing specialist services from hospitals, providing services in the community and being run by a self-selecting and self-perpetuating group of doctors is alarming.

The danger is double-edged: just at the point when the government has the ear of an increasingly consumerist public on matters of medical negligence, incompetence and arrogance, doctors decide to pack committees determining local health policy. Worse for them, they have a three-way responsibility — to the HA (which will pay them), to their peers (who elect them) and to their patients (whom they serve). Plenty of headaches can and will arise from the tensions between these potentially conflicting interests.

The BMA will not escape easily either, because its involvement puts its workers onto the management boards, where they may be less able than now to defend the interests of their peers. “Workers’ control” may be a good idea, but a trade union may be compromised by its new-found management function. Conflicts between the LMC leadership and ‘rank and file’ doctors will increase, jeopardising PCGs’ ability to deliver better services and cost containment in prescribing.

PCGs’ public meetings will be interesting. Opportunities for public engagement with local health policy are small but Blair’s government has increased them by making PCGs accessible. A dose of countervailing power, delivered at regular intervals, may be necessary medicine for ‘New Britain’s’ NHS. Fundholding will soon be dead: long live primary care groups!