The NHS White Paper is causing disquiet about plans to transfer billions of pounds into the hands of GPs effectively giving them control over 80 per cent of frontline services.
Nurses, charities and public health doctors are among those who this weekend questioned whether handing such far-reaching power to GPs will prove to be the best thing for patients – or the cheapest.
A last-minute rethink may have left the it looking more like a green paper after a committee of senior coalition ministers expressed unease at Andrew Lansley, the Health Secretary's failure to set out how GPs would be stopped from overspending.
The controversy will do little to assuage growing concern among coalition backbenchers that David Cameron, supported by Nick Clegg, is cutting too deeply into public spending. Although health spending is supposed to be protected from cuts, Lib Dem backbenchers are concerned that any efficiency savings made from the Lansley blueprint will be eaten up by increased costs elsewhere.
The King's Fund, a leading think-tank last night warned that mental health, children's surgery and transplant services were just a few examples of specialist care where GPs did not have the skills to make the best decisions. The King's Fund also said strategic organisations to ensure GPs performed well and provided value for money were essential.
The warnings come as Mr Lansley today announces plans to slash NHS red tape by £1bn as part of the coalition government's strategy to cut bureaucratic waste, and no doubt in an attempt to reassure the Treasury.
Having made no secret of his desire to scrap Primary Care Trusts and Strategic Health Authorities in opposition, Mr Lansley says the NHS will save £848m by cutting management costs in the 151 PCTs and the 10 SHAs – tomorrow's White Paper is likely to spell the end of both. Another £186m is expected to come from abolishing or trimming health quangos. Details are scarce but according to the Government's own calculations, this will result in savings equivalent to 30,000 nurses or 50,000 cancer drugs.
The substantial costs likely to arise from the 500-600 new GP consortiums are however excluded. Yet Chris Ham, chief executive of The King's Fund, said "transaction costs would increase substantially", as there will be four times as many commissioners negotiating, producing and monitoring contracts with hospitals than there are currently. Each of these GP consortiums is also likely to buy-in management consultants to help.
And the cost of payments to GPs – maligned for their burgeoning salaries under the previous government – for taking on this extra commissioning role remains unclear. Scrapping PCTs and SHAs will also be expensive as hundreds of redundancies are likely.
But GP commissioning has produced encouraging outcomes in the past. Similar plans under the previous Tory government during the 1990s reduced waiting times and widened the range of health services available, but failed to reduce costs as expected and patient satisfaction declined, according to think-tank Civitas.
James Gubb, director of Civitas's health unit, said yesterday the massive restructuring would likely lead to a short-term dip in performance, which could last three years.
Mr Ham pointed out that those previous successes were down, at least in part, to the highly motivated GPs who volunteered to become commissioners, and that the majority of GPs neither wanted, nor have the skills, to take on the extra work.
In an attempt to address these shortcomings, four leading public health bodies have written to Mr Lansley urging him to reconsider giving GPs total responsibility for commissioning NHS services as they believe a much broader perspective is crucial.
Dr Corinne Camilleri-Ferrante from the Faculty of Public Health said: "Public health specialists have the skills and the knowledge required to take a broad population perspective in commissioning healthcare and to judge the value of interventions across a wide range of different clinical areas. Our involvement in commissioning is absolutely crucial if we are to make best use of limited NHS resources."
Dr Peter Carter, chief executive of the Royal College of Nursing, said: "Wider multi-disciplinary teams would be better equipped to decide how best to meet patient needs. Nurses have regular contact with patients and understand the needs of communities, and so should play a central role in shaping local health services."
The country's largest mental health charity, Mind, warned against GPs forsaking obligations to support vulnerable patients because of the burden imposed by commissioning. Paul Farmer, chief executive, said: "It's crucial that these new responsibilities don't cut down the amount of time that GPs spend talking to patients, as people with mental health problems rely on them for support....
"While commissioning does present GPs with the potential to think locally, we must be careful not to create a micro-postcode lottery when there are already huge variances in the standard and types of mental health care patients receive."
The Royal College of GPs has welcomed the move. Chairman Professor Steve Field said: "It is important that GPs should be leading the NHS at all levels – but we must be given the appropriate resources to do this."
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