I work full-time as a GP in south London. Much of the challenge—and privilege—of the job is that almost anyone can walk into my surgery: from an anxious mother with a coughing toddler to a depressed retiree who can’t face getting up in the mornings. I am the first point of contact with the health service for almost everyone I see, and my job involves trying to do what is best both for the patient and the population as a whole: that is, trying to maximise the NHS’s limited resources by practicing medicine both efficiently and effectively.
This sometimes means not offering certain treatments, either because cheaper and equally effective alternatives exist, or because there is not enough evidence that they are effective. The NHS helps GPs make decisions like this via a number of guidelines, especially those of the National Institute of Clinical Excellence (Nice). Nice reviews the evidence for treating everything from childhood fevers to advanced kidney cancers, advising which strategies have been shown by research to be both effective and cost-effective—and which have not. Some frequently requested branded medications are “blacklisted” as they are no more effective than less expensive generic alternatives.
What do the coalition government’s plans for GP-led commissioning mean for all this? Under the proposed reforms, consortia of GPs will for the first time be directly controlling a substantial proportion of NHS spending, and will themselves decide which services should be “bought” for their local areas. Meanwhile, Nice’s powers are being curtailed, and a greater political emphasis put on reducing top-down decision-making.
The thinking behind this is that GPs are better-placed to judge a local population’s medical needs than anyone else, and that patients will in turn gain more influence on healthcare provision via interaction with their GPs. This makes intuitive sense, and many GPs are excited by the prospect of tailoring services to their local area and becoming advocates for patients. What concerns me, however, is this policy’s potential effect on the most central relationship in our health service: between a patient and their GP.
The therapeutic relationship between GP and patient is paramount in creating good healthcare: patients must be able to feel that they can trust GPs to look out for their welfare above all other considerations. If a patient know that their GP is directly determining what local resources will or will not be provided, this severely threatens that relationship. How will I as a GP be able to continue to have a healthy, caring relationship with local families who have an elderly relative suffering from severe dementia if I also sat on the local commissioning group that decided this area should no longer offer any community dementia nurse specialists?
The debate over public healthcare in the US last year was plagued by talk of “death panels”: committees established to determine the limits of publicly-funded care that terminally ill patients should receive. The power of such highly-charged issues to poison debate and policy alike is obvious.
Commissioning is, of course, more complex than consortia making unilateral decisions—and all decisions will theoretically be overseen by the new NHS commissioning board. Yet for a GP to be perceived as someone who says “no” to patients on a personal level may be the most damaging change the new bill brings about in people’s day-to-day experience of the NHS.
GP consortia will inevitably be under huge pressure not only to improve patient outcomes, but to deliver cost savings. Cost-effectiveness should not be a dirty phrase. Under the new system, however, it seems inevitable that patients will increasingly worry that GPs are motivated as much by financial pressures as by care requirements—and, worse, that GPs somehow stand to gain financially from withholding services (which is absolutely not the case).
There is also a real danger that the degree of localisation built into the new model will worsen health inequalities between different areas—and that the increased patient choices it promises will, as ever, benefit the wealthier and more proactive members of society at the expense of the least privileged.
GP commissioning may well get the government off the hook for instituting necessary cuts and compromises within an over-stretched health service. But at what cost to the fundamental relationships that our health service is based on?
Also in this month’s Coalition Britain special:
Stryker Maguireon the Coalition one year on
Charles Kennedy explains why he has come round to the coalition.
The Economist’s Janan Ganeshon why Cameron needs to fight for his bold ideas
Anatole Kaletsky argues that the cuts will ruin the economy—but for Tory benefit.
