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GPs say no to glassy eyed evangelists on speed

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Friday, 19 November 2010

GPs say no to glassy eyed evangelists on speed

“Thank goodness all I’ve got to do is run a war in Afghanistan,” said Surgeon Rear Admiral Lionel Jarvis, closing the morning’s proceedings on the first day of the NHS Alliance Conference yesterday in Bournemouth.

To appreciate the joke you had to have sat through the rear admiral’s talk, which was followed by half a dozen other speakers rehearsing the challenges facing GPs.  Though scarcely light, the rear admiral’s moving account of the difficulties facing medical teams on the front line was the nearest thing the agenda offered to relief from the thorny issues of GP commissioning.

Michael Dixon, the dangerously affable chairman of the Alliance, opened the show with a rousing call to his colleagues.

“Do not allow history to call general practice or primary care timid, workshy or small-minded. We cannot allow fear, apathy or laziness to prevent this becoming the NHS’s finest hour,” he said, in a speech littered with warnings to GPs not to pass up the opportunity presented by the white paper.

His address was delivered with passion and warmly received. Nevertheless, when Phil Hammond, the TV doctor, asked for a show of hands to gauge GPs' faith in the new policy, only a few were raised in an auditorium containing 1000 people.

Jim Easton, the Department of Health’s director of the cold light of day and never a man to shy away from a risky analogy, described a film in which when the gates of a concentration camp are finally opened, the prisoners do nothing but mill around. One gets the feeling that the secretary of state for health would be rather disappointed if having liberated the NHS, all the inmates decided to stay in the compound.

The real problem and the reason for the apathetic show of hands is not that GPs lack the will for commissioning, but that at a time of financial crisis the thing that politicians and civil servants keep describing as an opportunity looks suspiciously like a poisoned chalice.

As Jim Easton pointed out, the idea of the GPs as fall guys for the financial crisis is nonsensical. “Andrew Lansley’s plans far predate the financial pressure and look much further into the future,” he said.

That may be true but for all the attempts to present austerity as a sharpener of wits and steeler of nerves, the risk of financial failure and continuing uncertainties about the individual and collective liability of the commissioners of the future continue to cloud the optimism of GPs.

The danger is that the government’s insistence that it will not tell the NHS how to do what needs doing is not the popular message it supposes. The villain of the piece is not the culture of dependency that has left us addicted to guidance and incapable of independent thought. It is that there are questions that only the centre can answer and it is disingenuous to pretend that GPs can find the answers themselves.

Probably the most important is around the perverse incentives that reward the NHS for stuffing hospitals with people who could be treated better and more cheaply somewhere else. The reform or abolition of Payment by Results was a constant theme of this year’s Alliance event.

Other issues include the fear of inherited debt from PCTs and the career risks GPs feel they may be taking in launching into GP commissioning.

As Dame Barbara Hakin, national managing director of commissioning development, said, the career risk is real but not severe. GPs who don’t take to commissioning have clinical jobs to fall back on. She added pointedly that the same cannot be said of NHS managers.

But if GPs needed a reason to stop feeling sorry for themselves it was provided by Sir John Oldham, a GP and clinical lead for the QIPP programme. During one of the afternoon sessions, Sir John revisited the theme of NHS finances, which he reminded us are acute now, but will remain in a chronic condition long after the immediate crisis has been averted. He quoted statistics that show that by 2065, the US health bill will consume 100% of GDP. The projections for Japan and the UK lead to a similar conclusion.

He rattled off some more figures: 76% of health and social care spending goes on people with one or more long-term conditions, the cost of which is set to rise by 60% by 2014. 64% of hospital admissions are accounted for by people with two or more chronic conditions. Even if the economy was booming, the long view is that without radical action the health service is not sustainable.

“If we fail, we fail our friends, our relatives, our communities,” Sir John said. There were murmurs of assent. One of the GPs in the room thanked Sir John for clarifying the purpose of the white paper. 

The GPs got it because here was somebody talking their language. Redesigning care to keep people out of hospital, addressing the long-term problems that fill GP surgeries every day – these are the subjects that engage GPs. Sterile debates about statutory functions, the size of consortia and tariffs overwhelm them with fear that they are turning into PCT managers.

Armed with enough common sense and with a few remaining important obstacles cleared from their path, you were left with the impression that GPs are up for this.

They remain to be convinced and need to be reassured, but there is more light than heat in the debate now.

And if missionary zeal was lacking at the Alliance event, perhaps this is no bad thing. As Michael Dixon said during his keynote address: “What we don’t need is glassy-eyed evangelists on speed.”