Since Andrew Lansley turned the world upside down with the publication of his White Paper last July signalling the biggest revolution in the health service's 62 year history, there has been fevered speculation on what the changes will mean for patients, hospitals and the NHS.
Yet seven months on we still don't know whether the key players in the reforms – the GPs – will rise to the challenge. The Health Secretary knows that their co-operation is critical to driving through the changes he has planned. Without it the revolution could sink into the sand.
At its heart is the plan to transfer control of £80 billion of NHS spending to GPs and create a market in healthcare open to "any willing provider" – including private firms. The result could be an NHS that looks utterly different from what we have at present. In place of a directly managed system of hospitals and GPs all provided by the NHS, we may end up with a regulated industry in which BUPA, Boots and other private organisations compete to run hospitals and clinics, and even GP surgeries, providing care to NHS patients.
But while the British Medical Association, the Royal College of GPs and other medical organisations have issued statements critical of various aspects of the plans, it is still unclear what the opinion is among grassroots GPs who will hold the budget reins under the new system.
That may be revealed next month when the BMA holds an emergency meeting on the reforms, providing the first opportunity for rank-and-file GPs to make their feelings heard.
Ministers claim widespread support on the basis that thousands of GPs have signed up to join 140 pathfinder consortia covering half the population. But critics claim most have done so reluctantly, believing the White Paper is a "done deal" and that they risk missing out if they hang back. A survey by the RCGP of almost 2,000 of its members last week showed almost two thirds opposed the reforms. The Kings Fund found in a survey last autumn that fewer than one in four doctors believed the reforms would improve patient care.
David Cameron, the Prime Minister, has said that without modernisation the NHS will become unaffordable. The aim is to produce a leaner, more efficient, more responsive organisation that can adapt to the changing needs of patients in the 21st century and deliver more care, more effectively where patients need it, close to home.
The worst outcome – and one that officials acknowledge is a real possibility if GPs and other key players fail to co-operate – is that after all the disruption and expense of implementing the reforms, nothing changes.
Are GPs prepared to put their backs to the wheel and deliver? And what will it mean for patients? Here two leading family doctors give contrasting views.
Pro-reform: Peter Weaving - 'We were in a real mess. We needed change'
Peter Weaving runs one of the six "localities" that together comprise the GP consortium for Cumbria. He and his colleagues at Brampton medical practice manage a budget of £200 million for 100,000 patients in Carlisle and the surrounding area. Since last April they have had direct control of 60 per cent of the budget and from next April they will take over 97 per cent.
They are ahead of the rest of the country because three years ago the NHS in Cumbria was bust, with a £50 million overspend, and managers decided the way out of the impasse was to give the GPs the money (under "practice-based commissioning", Labour's less radical version of what Andrew Lansley is now proposing).
"We were in a real mess," Dr Weaving says. "We needed to make significant changes. We needed smaller and more efficient hospitals and more care delivered in the community. There were some very difficult public meetings."
The upshot was that 100 beds were shut at Carlisle NHS hospital trust, but all nine community hospitals threatened with closure were saved. Slimmed down and spruced up, they are now part of the provision for the elderly, avoiding expensive admissions to the district hospital that cost £3,000 a time.
Localities can keep 10 per cent of any savings to invest in new services. So they have an incentive to work better and do things differently. GPs are carrying out more procedures in the community, including the administration of intravenous antibiotics. Around 4,000 out-patient appointments for diabetes and dermatology a year are now handled by GPs that would have previously involved a hospital visit.
"Someone may be frail and off their legs but may not need heavy duty hospital care. Being admitted to hospital is a big thing. Their support systems evaporate and it can be difficult to get them home. Often they do better if they are treated at home," Dr Weaving says.
"The very clear lesson we have learnt is that you can't write a contract and say give me this or I won't give you the money. You need a face-to-face meeting where [GPs and hospital doctors] can negotiate.
"We are only half way down the road of what we can do. We see the NHS reforms as a massive endorsement of the road we are already on."
Anti-reform: Kambiz Boomla - 'It's is not about giving power to doctors, it's a shift in provision'
Kambiz Boomla and his colleagues at the Chrisp Street Health Centre in Tower Hamlets, London, have not needed market incentives to develop with neighbouring practices a care package for diabetes patients which keeps them out of hospital. It is based on a network of GPs who collaborate and a hospital consultant who comes out once a month to discuss difficult cases.
"We have worked out a care pathway. But we have not invited Bupa or Boots – just our local hospital," he says. "We have a better service but the Government wants us to go out to tender to make care subject to the market. You then have competition between the various companies and an increase in transaction costs. What GPs want is to sit down with their local consultants and do it collaboratively."
Once they have developed an idea that works, the natural thing would be to pass it on to others and spread the word. "But if it's a private company, they would say it is commercially confidential," Dr Boomla says. "If you want it, you have to pay for it. It is a different ethic."
Andrew Lansley's vision is patients will exercise choice over where they are treated. But nine out of ten patients in Tower Hamlets want to go to the Royal London Hospital. "Perhaps a predatory Foundation Trust could see custom coming their way," says the GP. "But when times are hard and cash is short, people realise if we bankrupt our local provider, no one will gain."
Dr Boomla says incentives are already present in the NHS to bring about change. "Take obesity surgery: it saves the NHS money within two years for very fat people. But we haven't got the money to invest to save. So if we move some of another activity – diabetes care – into the community, we can save cash and commission more [weight-loss] surgery."
Making GPs budget holders as well as clinical decision makers will leave them in a "very uncomfortable position", he says."It will undermine patients' trust. If I say to a patient I will refer you for a hip replacement but I regret there is a long wait, they may say: 'But it was you who made the decision to cut the number of hip operations.' This Government is deadly serious about making funding cuts to the NHS. The real message of the reforms is not about giving power to GPs – it is about the shift from NHS provision to any willing provider, allowing the private sector to take over the NHS."