value – not simply a means to an end.


So critics who complain of the potential consequences of these moves to the NHS are missing the point. Market reforms are not a means to an end but an end in themselves.


There is a clear rationale behind this set of reforms, building on Labour’s advocacy of expanded choice, that markets are a social good where the alternative is monopoly provision.


This focus on the intrinsic benefits of the market (as opposed to the potential performance benefits of market mechanisms) also explains the government’s introduction of much more competition in provision with, presumably, much more private sector involvement in the NHS.


These principles are to be welcomed. The NHS is yet to shake off its paternalistic tendency to deride choice and competition as unwelcome elements set to debase our national treasure. And that healthcare is both state financed and state operated has led to an unhealthy fixation with hospitals as the emblem of the NHS when buildings should never be as important as values.


We need to move away from the idea that only public sector providers have the skills and the virtue to deliver care in the NHS.


So far, so good. Why then do I argue that Mr Lansley may end up regretting the consequences of his reforming zeal? The practical fact is that choice, competition and the development of truly social markets in healthcare is not possible without high quality commissioning. And there are four reasons why the government’s reforms to


Jul/Aug 10


It is too much of a logical leap to argue that


because GPs are closest to patients they are therefore best equipped to commission services on their behalf. It’s like asking your waiter to manage a restaurant


commissioning will not deliver the right outcomes for patients and taxpayers.


First, GPs do not have the commissioning skills that are necessary to take on this role from existing PCTs. A spokesman for a number of GPs in East London said:


“GPs are very capable people but they are not accountants and they are not financially-minded and in order for us to complete the complexities of the work that we will face, we couldn’t manage it in-house and we would also have to outsource to a private company”.


It is too much of a logical leap to argue that because GPs are closest to patients they are therefore best equipped to commission services on their behalf. It’s like asking your waiter to manage a restaurant. They might know what you want to eat but would be ill equipped to order stock, manage the premises and deal with the chef.


GPs simply do not have the skills to take on these responsibilities without substantial external support and guidance. This means that the many redundant PCT staff will end up selling their services back to new GP consortia and many private sector commissioners will also work on behalf of these groups.


So the outcome of this policy will not be GP led commissioning but the outsourcing of commissioning to as yet unknown groups. There is no evidence to suggest that this


is a desirable move that will move decision making closer to patients.


Second, these commissioning reforms lack the active support of the groups which will have to drive them forward. Where are the GPs who want to take on commissioning responsibility?


At the time of writing there has been no statement issued by the Royal College for GPs regarding this fundamental change to their role. This silence cannot be taken for unqualified support.


The limited number of GPs who chose to become involved in practice based commissioning was very small. Before the election the Conservatives argued that this was because no ‘hard’ budgets were on offer to entrepreneurial doctors.


But again there is no evidence to support the idea that GPs are salivating at the prospect of getting their hands on NHS cash to spend on behalf of their patients. How can we rely on the efforts of a group of doctors who seem to have no desire to take on this difficult and complex task?


Third, despite the introduction of an Independent


Commissioning Board, it is not clear how GPs will be held to account for how they spend around £80bn of public money.


While the government is rightly trying to end a culture of political micro-management, for the voting public the dropped bed pan still resounds down the corridors of Whitehall.


So when unpopular decisions are taken by GP consortia (such as closing a hospital) MPs will still be on the receiving end of local anger and will still look to the secretary of state for answers.


What will the relationship be between the secretary of state and the new board? What powers of redress will local people have from GP consortia? What will happen to GP consortia that mismanage their budgets?


The fourth and last reason is the impending financial squeeze. The scale of the financial slowdown is unprecedented and so the last thing the service should be doing is reorganising yet again.


It’s as though BP were to respond to the oil spill with a decision to overhaul the company’s management structure.


They would be rightly criticised for failing to concentrate on the job in hand. The same criticisms will be levelled at the NHS as it spends precious time inventing a structure for tomorrow to deal with a problem that is here today.


Commissioning in the NHS must work well if we’re to reap the benefits of a diverse provider market and genuinely patient centred services. But the breathtaking scale of the reforms outlined in the White Paper poses a real threat to the ability of the health service to cope with the breathtaking scale of the financial challenge.


His wish to run the health service granted, it may not be long before Andrew Lansley pines for the relatively easy days of opposition.


nhe 15


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