The NHS Consultants' Association

Primary Care Shake up will Shake NHS Foundations

Statements such as "The NHS will never be the same"; "It's the end of the NHS" have become increasing common since the first market reforms of 1990. We have moved from a GP-led NHS (fundholding) through a Primary Care-led NHS and now have arrived at the Patient-led NHS according to the latest bomb-shell from the NHS chief exec Nigel Crisp.

Health care professionals working in the community - GPs, district and practice nurses, health visitors and so on - have often cried out for more attention to be paid to primary care where 90% of the patient contacts with the NHS occur for 10% of the NHS budget. This latest move by the NHS executive - in preparation for a winter white paper "Health Care Outside Hospitals" - provides an unanticipated answer to that plea with a huge injection of market rhetoric, a speeding up of the commercialisation of the NHS and a speeding up of the change from a providing and commissioning organisation to one that pays for health care provided by others.

The specifics are (quoting from the DoH document 'Commissioning a Patient-led NHS'):

• " "Better engagement with local clinicians in the design of services .... with universal roll-out of Practice Based Commissioning by December 2006"
• " "PCTs (Primary Care Trusts) will become patient-led and commissioning-led organisations with their role in provision reduced to a minimum.". "As PCTs focus on promoting health and commissioning services, arrangements should be made to secure services from a range of providers... This will bring a degree of contestability to community-based services, with a greater variety of service offerings and responsiveness to patient needs". "PCTs acting as provider of services only where it is not possible to have separate providers - and with arrangements for separating out decisions on commissioning from provider management"
• " "Re- configuration of PCTs (again!) by October 2006 and of SHAs by April 2007 alongside the reform of ambulance services described in Taking Healthcare to the Patient". "SHAs will be expected to deliver a significant reduction in management and administrative costs (again!) through their configuration proposals". [NHS management costs are already below international comparators]
• " "[all NHS Trusts] to move towards NHS Foundation Trust status by April 2008". "Alongside this programme for NHS Trusts, there will be a progressive move towards greater use of other providers, including those from the independent sector"

What does all this mean?

Essentially the wholesale privatisation of community services - district nurses, health visitors, dieticians, community hospitals, services for people with Learning Difficulties and so on. PCTs will give up providing any services in the community but no mention is made of any replacement organisation only the role of the 'independent sector'. No mention is made of the public health function in designing services to meet population needs nor how services not taken up by the independent sector - low profit and/or high cost - will be provided.

All acute trusts will have to become Foundation Trusts and will be encouraged to compete for contracts to provide care for chronic conditions. Presumably this is to rack up their income under Payment by Results and to create direct competition between themselves and general practices. Meanwhile general practices will be forced into Practice Based Commissioning and 'control' the contracts let by PCTs with acute trusts.

Either this is a very clever system that I can't understand or a recipe for NHS meltdown, planned or inadvertent. The mantra is clear - private sector good, public sector bad - but so are the dangers - competition instead of co-operation, fragmentation rather integration. The NHS will become a bill-paying organisation. GPs whether as self employed entrepreneurs or employees of 'Tesco Health' may well be pricing themselves out of this new market. Already nurses, health care assistants and other less expensive health professionals are providing packages of care according to computer programmes.

We know that health care is more complex than selling insurance or running supermarkets. People requiring care are not simply 'consumers looking for the cheapest health commodity'; nor can their complex ailments be fixed by algorithms alone. Caring must remain coupled with compassion rather than profit; the NHS should remain an integrated, public service; and primary care in all its complexity should remain locally coherent and firmly bound into the matrix of NHS and social care.