Rationing according to clinical need has been replaced by rationing according to the GP's ability to pay

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Bob, a Birmingham GP, has just lost Bella, his psychiatric nurse. Well not his exactly, doctors aren't allowed to own nurses any more - but Bella looked after his neediest patients. It wasn't an accident or carelessness or something nasty in the lift of a tower block. She's been poached (as in stolen, not cooked in a knob of butter over boiling water) by a group of fundholding GPs in Staffordshire.

Poaching is all the rage in our fab new market-driven NHS. Trust hospitals headhunt each other's anaesthetists with tempting offers of a free parking place, and personnel managers fly to all comers of the earth in search of nurses who'll work for a pittance. GPs have for years tried to seduce each other's patients, or at least the ones who'll build up the list size without ever troubling the doctor, but knicking (sic) nurses across county boundaries is a first.

To be fair, Bella didn't actually work for Bob. She's employed by his health authority, who's community psychiatric services have been purchased by the fundholding GPs. These services rely for their success on, among other things, the local knowledge of the staff, so buying them from a health authority 40 miles away might seem like a bit of a risk. But if the price is right, who cares?

Unfortunately, Bella doesn't want to move. She loves working in Birmingham, knows the area and the patients well and doesn't relish whipping round the M42 every morning to unfamiliar territory. Fundholding GPs have the power to do some very innovative things, but making nurses miserable isn't one of them.

Nicky is a consultant radiologist and she's not very happy with fundholding either. "In my hospital, fundholding GPs get open access to any radiological procedure under the sun - CT scans of the toe, MRIs of the navel, you name it - whereas non-fundholders have to fight tooth and nail for anything more complicated than a chest X-ray."

This gripe - that rationing according to clinical need has been replaced by rationing according to the GP's ability to pay - is nothing new. Rather, it is now so widespread that it's a written law. Since the reforms were introduced, NHS managers have issued hundreds of memos directing their staff to give preferential access to fundholders. Clinics have even been set up exclusively for their patients. Just how many have jumped the queue ahead of non-fundholders' patients is hard to gauge, but the very fact that it has become acceptable to do so is grossly iniquitous.

So why do consultants like Nicky put up with it? Fear, for a start. "There's a gagging clause in my contract and I've no doubt I'd be out on my ear if I went public." This frightens me, too. The old model of medical training - keep your trap shut and lick the right arses until you reach the top, then say what you want - has been replaced by the new model. Keep your trap shut all the time. There is nothing more sinister and sobering than a muted consultant. "If I refuse to do an immediate MRI scan for a fundholder because there are clinically more pressing things I should be doing, he or she'll get it done at a neighbouring trust and we'll loose the pounds 500. If that happens too often, I could be picking up my P45 ... You won't quote me on this, will you?"

This is, of course, a very one-sided view of the reforms, as a fundholding colleague points out: "There's no doubt that it's more satisfying being in control of certain treatments and investigations, and that we're offering a better service to our patients. They're even commenting on it unprompted, especially since we saved enough money to revamp the surgery. Everybody loves the central courtyard with its mini-arboretum."

"Don't you feel at all guilty?"

"I do when I think of all the single-handed GPs who were never eligible to join the scheme and still work in tin shacks treating some of the sickest patients. I'm sure they could have done with the money more than us, but then we're just opportunists. We don't make the rules."

Quite. An administratively cumbersome scheme that thrives on selective advantage over your more needy colleagues and their patients may not universally be regarded as progress, but fundholding has at least given GPs the mirage of control over their destiny. Which is more than can be said for Nurse Bella. "I've been told to shut up and follow the money." Still, help could be on the way. Dr Bob's thinking of becoming a fundholder so he can buy her back.

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