Andreas Whittam Smith: GPs will have to sprout angel wings to handle this madness

So the path to enhanced localism goes via the Kremlin. It is a weird way to go
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If you thought the furore over higher education and tuition fees was bad enough, I should remind you that the National Health Service, a much more frightening character, is shortly to come on stage. Its problems were well put the other day by the MP for St Ives and the Isle of Scilly, Andrew George, in a comment he addressed to the Secretary of State for Health, Andrew Lansley.

"Secretary of State, can I ask you the 'Come off it' question? You yourself have said that in order to achieve your objectives you have to achieve efficiency savings in both health and social care that are not only challenging, but unprecedented; that you have to defy gravity with regard to NHS inflation... and at the same time there is arguably a very significant reorganisation, which some might even say is like a nuclear device going off at the commissioning level. Are you asking us totally to suspend our disbelief that all this can be achieved?"

This exactly captures the difficulty. All experience shows that the massive reorganisation of an institution is incompatible with a simultaneous increase in efficiency. The relationship is usually negative. Efficiency generally suffers while big changes in the structure of an enterprise are undertaken. You don't have to be a management consultant to understand that. If there is to be an improvement, it will come later. Worse still, as the National Audit Office reported last March, a large number of Whitehall reorganisations had been "unnecessary". For central government bodies had been weak at "identifying and systematically securing the benefits they hope to gain from reorganisation". The National Audit Office calculated that close to £1bn had been wasted in this way during the previous 20 years.

The current NHS reorganisation is likely to be a further example. It concerns the provision of primary care, the services you use when you first have a health problem such as doctors, dentists, opticians, pharmacists, NHS walk-in centres and the NHS Direct telephone service. One hundred and fifty-one primary care trusts, that is one for every 340,000 people, manage these at present. So they are local institutions. Indeed, as the Department of Health intoned until only the other day: "As they are local organisations, they understand what their community needs, so they can make sure that the organisations providing health and social care services are working effectively".

Yet Mr Lansley believes that these primary care trusts are not local enough. His White Paper, published in July, said that in order to shift decision-making as close as possible to individual patients, the Department of Health would devolve power and responsibility for commissioning services to local consortia of GP practices. And he spoke, too, of increased accountability to patients and of democratic legitimacy. But surely endowing GPs with democratic legitimacy is stretching things a bit far. My doctor would have to grow angels' wings to live up to it. Or, as Mr George might say, "Come off it". This is the first problem – localism gone mad.

In his White Paper, Mr Lansley also argued that commissioning by GP consortia would mean that the redesign of local services would always be clinically led and based on more effective dialogue and partnership with hospital specialists. But this raises the question whether the not-sufficiently-local primary care trusts have also been clinically illiterate. If so, it would have been a strange state of affairs. This implausibility is a second problem.

Difficulties are already appearing. Imagine that you work for a primary care trust and you learn from the White Paper that your organisation will cease to exist on 1 April 2013. What would you do? Start looking for another job and leave as soon as you obtain one. This seems to be exactly what is happening. At a recent session of the Commons Health Committee, Dr Sarah Wollaston, who worked for 16 years as a GP in rural Devon before becoming the Tory MP for Totnes, told Mr Lansley that in many areas of the country, managers of primary care trusts were disappearing and the trusts themselves were "effectively in meltdown". And she asked: in such areas, how will we deliver an efficiency challenge at all, let alone deliver it in a logical way? This a third problem.

Sir David Nicholson, chief executive of the NHS, answered her straight away: "I think you're absolutely right ... If you were to ask me whether I think we can sustain 152 independent primary care trusts between now and 1 April 2013, I would say that we cannot. Increasingly, in parts of the country, we see that we cannot do that now."

So what happens next? Primary care trusts are being encouraged "to cluster together" before finally being extinguished. They are like the mortally wounded huddling together on the stricken battlefield. At the same time, the centre is planning to exert a strong grip on the situation. "We will have to take a very tight rein in relation to the management of finance," said Sir David, what he described later as "Stalinist controls". So the path to enhanced localism goes via the Kremlin. It is a weird way to go.

Sir David was then asked if he had any idea of the number of primary care trust staff who have left this year. In reply, he said that in fact the NHS had already offered a scheme that gave primary care and strategic health authority staff the opportunity to leave – even though the NHS did not wish the trusts to go into meltdown! At all events, more than 2,000 people took the opportunity before the scheme was closed. This again is odd. You want to keep the primary care trusts functioning until 2013 and straight away you provide a redundancy scheme. It beggars belief. Ah, replied Sir David, in answer to the obvious criticism, it was a scheme called the mutually agreed resignation scheme. It was not just a question of someone saying that they wanted to go; "we had to agree that they are the kind of people who we can do without, in a sense".

This is what managers always seek to achieve with redundancy schemes, and it is pie in the sky. The better staff that could easily find another job come forward immediately and, although managers can refuse their request, they rarely do so because the consequence would be a very resentful employee. What we face, then, is a dysfunctional NHS for the next two to three years. And the discontent this is likely to cause will far exceed the furore generated by tuition fees.