Leading Article: Under doctors' orders - where the NHS belongs

Related Topics
Labour was elected to power on a promise to cut National Health Service red tape and end the inequity introduced by the Tory health service reforms. The internal market - condemned by the British Medical Association as an "infernal bazaar"- had set trust against trust, created a bonanza for managers and administrators and consumed forests of trees to produce the thousands of contracts daily exchanged between hospitals, GPs and health authorities.

Seven months on, the new Government has devised a plan that is radical in intent but which seeks to improve on the old order, not to overthrow it. Ministers recognise that a major shake-up would not be welcomed by the white coats in the front line. Evolution, not revolution, is the word.

The internal market is effectively abolished although something close to it remains in the form of the "service agreements" between the GP collectives and the hospitals with whom they choose to work. It is the end of GP fundholding but opposition from disgruntled fundholders is likely to be minimised by the vast new powers that are being handed to family doctors.

This is the kernel of the new plans and they go further than anything that has so far been hinted at. The logic is impeccable. Putting GPs who are in daily contact with patients in the driving seat of the NHS ensures that the commissioning of services is anchored in a grassroots understanding of patient needs.

But will the GPs have either the interest or the managerial capacity to run the commissioning process? Most GPs want to treat patients, not sit on committees and shuffle bits of paper. Concern about the expansion of GP fundholding, which currently covers more than half the population, centres on whether the remaining non-fundholders have the managerial nous to handle their own budgets.

The GP collectives proposed in the White Paper will need extensive managerial support. They will function as mini health authorities, and since there will be more of them - perhaps 500-600 compared with the existing 190 health authorities - it is hard to see how this will contribute to the oft-promised reduction in grey suits.

There are questions too about incentives to efficiency and improved performance. Under the existing market system, competition provides the lever. GP fundholders can shop around for the best deal from their local NHS trusts (or even distant ones) and get to keep any savings they make on their annual budgets for reinvestment in their practices - a powerful individual incentive which will be lost in the new system.

Nor will the abolition of fundholding end inequity. The charge is that GP fundholders with their superior bargaining power have been able to negotiate advantageous deals for their patients which have led to queue jumping of hospital waiting lists and the introduction of a two-tier service. Critics point out, however, that switching budgets from fundholders to GP collectives will simply shift inequity from the local practice level to the level of the collective.

The most radical aspect of the plan is the decision to merge hospital and GP budgets so that the GP collectives can decide how care is to be provided. Budgets for drugs, health visitors, community nursing and hospital services can then be balanced against one another to provide person-centred rather than institution-centred care.

The scheme has something in common with American health maintenance organisations which have a fixed budget to provide all necessary care to their members. By ensuring members remain healthy, costs are reduced and when care is needed there is an incentive to provide it as close to people's homes as possible, where it is cheapest. In the same way the aim of the GP collectives will be to provide services in the most cost-efficient way with an emphasis on out-patient and day-case care.

In the long term, budgets might be created for specific services such as cancer or paediatrics which would cross the boundaries between GP, hospital and community provision.

An important feature of the White Paper is that it lays down no time- scale for introduction of the plan. Labour believe they will be around for some time and can afford to be leisurely. The recent document inviting bids under the health action zone initiative to raise health-care standards in deprived inner cities does not envisage evaluation until after the next election.

Under the market system, the NHS has lacked strategic direction. It has grown by accretion, with extra services bolted on in response to demand. The benefit has been to turn the health service from a monolithic, inward looking institution into a responsive, outward looking organisation. The test for the Government's new proposals will be whether they preserve that responsiveness while adding new purpose.

React Now

Latest stories from i100
Have you tried new the Independent Digital Edition apps?
iJobs Job Widget
iJobs General

Guru Careers: Software Developer / C# Developer

£40-50K: Guru Careers: We are seeking an experienced Software / C# Developer w...

Guru Careers: Software Developer

£35 - 40k + Benefits: Guru Careers: We are seeking a Software Developer (JavaS...

SThree: Trainee Recruitment Consultant / Resourcer

£18000 - £23000 per annum + Commission: SThree: As a Trainee Recruitment Consu...

Ashdown Group: UI Developer - (UI, HTML, CSS, JavaScript, AngularJS)

£25000 - £40000 per annum: Ashdown Group: UI Developer - (UI, JavaScript, HTML...

Day In a Page


In Sickness and in Health: 'I'm really happy to be alive and to see Rebecca'

Rebecca Armstrong
Abuse - and the hell that came afterwards

Abuse - and the hell that follows

James Rhodes on the extraordinary legal battle to publish his memoir
Why we need a 'tranquility map' of England, according to campaigners

It's oh so quiet!

The case for a 'tranquility map' of England
'Timeless fashion': It may be a paradox, but the industry loves it

'Timeless fashion'

It may be a paradox, but the industry loves it
If the West needs a bridge to the 'moderates' inside Isis, maybe we could have done with Osama bin Laden staying alive after all

Could have done with Osama bin Laden staying alive?

Robert Fisk on the Fountainheads of World Evil in 2011 - and 2015
New exhibition celebrates the evolution of swimwear

Evolution of swimwear

From bathing dresses in the twenties to modern bikinis
Sun, sex and an anthropological study: One British academic's summer of hell in Magaluf

Sun, sex and an anthropological study

One academic’s summer of hell in Magaluf
From Shakespeare to Rising Damp... to Vicious

Frances de la Tour's 50-year triumph

'Rising Damp' brought De la Tour such recognition that she could be forgiven if she'd never been able to move on. But at 70, she continues to flourish - and to beguile
'That Whitsun, I was late getting away...'

Ian McMillan on the Whitsun Weddings

This weekend is Whitsun, and while the festival may no longer resonate, Larkin's best-loved poem, lives on - along with the train journey at the heart of it
Kathryn Williams explores the works and influences of Sylvia Plath in a new light

Songs from the bell jar

Kathryn Williams explores the works and influences of Sylvia Plath
How one man's day in high heels showed him that Cannes must change its 'no flats' policy

One man's day in high heels

...showed him that Cannes must change its 'flats' policy
Is a quiet crusade to reform executive pay bearing fruit?

Is a quiet crusade to reform executive pay bearing fruit?

Dominic Rossi of Fidelity says his pressure on business to control rewards is working. But why aren’t other fund managers helping?
The King David Hotel gives precious work to Palestinians - unless peace talks are on

King David Hotel: Palestinians not included

The King David is special to Jerusalem. Nick Kochan checked in and discovered it has some special arrangements, too
More people moving from Australia to New Zealand than in the other direction for first time in 24 years

End of the Aussie brain drain

More people moving from Australia to New Zealand than in the other direction for first time in 24 years
Meditation is touted as a cure for mental instability but can it actually be bad for you?

Can meditation be bad for you?

Researching a mass murder, Dr Miguel Farias discovered that, far from bringing inner peace, meditation can leave devotees in pieces
Eurovision 2015: Australians will be cheering on their first-ever entrant this Saturday

Australia's first-ever Eurovision entrant

Australia, a nation of kitsch-worshippers, has always loved the Eurovision Song Contest. Maggie Alderson says it'll fit in fine