In the dark on GP commissioning

Last week's data on public sector pay showed that in the NHS the managers do not have it all their own way. Based on Freedom of Information requests, the BBC and the Bureau of Investigative Journalism found 10 GPs earning more than £300,000 a year, well above the £278,000 earned by the NHS chief executive Sir David Nicholson ( article ). Two unnamed GPs in London and Birmingham each earned £475,000 – more than any other public servant save three BBC executives. Family doctors have had a semi-detached relationship with the NHS from its 1948 foundation. Many opposed it and refused to take part, only to change their minds when they saw its popularity. Unlike almost everyone else who works for the NHS, most GPs are not employed by one of its trusts, but act as contractors. Nevertheless, they are well rewarded for their work: the British Medical Association answered queries about the high earning GPs by pointing out that most earn a mere £100,000. GPs can argue that their independence means they are more likely to do what is right for their patients, rather than the NHS. But this makes health secretary Andrew Lansley's decision to hand them 80% of the English NHS's budget, by replacing primary care trusts with GP commissioning consortia, politically brave. One of the first points made at an NHS Confederation discussion last week on the Lansley's plans was that it increases the "agency problem" resulting from the fact that the interests of GPs and patients are not necessarily the same. One speaker at the event, which was run on a non-attributable basis, said that GPs do not like to take tough budgetary decisions, instead preferring to campaign for more money. Another said that very few GPs are engaged with what hospital trusts do. Yet another pointed out that the NHS has been here before, describing the changes as largely technocratic. The Conservative government under John Major established GP fundholding, which led to more than half the UK's GPs buying services for their patients but arguably disadvantaged the patients of non-fundholding doctors. The first of the Labour government's many reorganisations of the NHS involved ending the system and GPs on the boards of primary care groups, which began to commission healthcare for their areas in April 1999. But within a year Tony Blair's government began to replace these groups with primary care trusts which are not controlled by GPs. (There was yet another reorganisation in 2006, when the 300 PCTs in England were rationalised into 152. It gave them greater scale and in most cases a fit with local authority boundaries, but the lack of GP control remained.) Free our data, again? Very little is clear about the shape and nature of GP commissioning consortia. However, health campaign group London Health Emergency points out that the organisational changes in Lansley's white paper could greatly reduce the amount of information available on NHS organisations – contradicting the government's stated aim of opening public access to state sector data. Non-foundation primary care and acute trusts are relatively open bodies: they have regular meetings which members of the public and press can attend, and they publish the agendas, board papers and minutes of these meetings online. But that is not the case for foundation trusts, which are only obliged to publish an annual report, and Lansley wants all remaining NHS trusts to become foundations. "The annual reports are normally three or four months after the year they are talking about has ended, and it's public PR stuff," says John Lister, senior lecturer of health journalism at Coventry University and London Health Emergency's information director. "If you want to know what's really happening, it's not a good source." There could be even less information available from GP commissioning consortia, Lister adds: if they are established as social enterprises they may be exempt from Freedom of Information requests, which do apply to foundation trusts. The Department of Health says the government is committed to transparency, but adds that it is still consulting on how GP consortia will be established. It has no plans to allow foundation trusts to stop publishing annual reports, but says they have a greater degree of autonomy. That does not imply forcing them to publish more information. Aside from transparency, most PCTs now have boundaries, and the same names, as their local councils. Lansley sees councils playing a major role in public health, but unless he decides that GP consortia should cover the same areas as primary care trusts, the mismatches of the era before 2006 seem likely to reappear. Lister says that GPs could be given control simply by re-establishing primary care groups to control the existing PCTs, preserving the transparency and the alignment with council boundaries. "You don't need to go through this huge leap in the dark of deconstructing the NHS," he adds. Late last week, Lansley wrote to GPs encouraging them to work with PCTs to set up shadow commissioning bodies as soon as possible, which might make the recycling of those organisations more likely ( article ). However, he also wrote that the commissioning consortia should have the form that "most suits your own particular local circumstances". The "huge leap in the dark" looks pretty likely.