A suburban GP explains why he thinks the government has broken the NHS up into clinical commissioning groups
"There have been some good developments in the NHS over recent years: mental and physical health are now recognised as inextricably linked, and it’s a government aim to integrate the two spheres. This has, to my embarrassment, been long overdue. But overall we find ourselves in a dysfunctional system created by hasty reforms conducted without sufficient consideration for the consequences.
Primary health care used to be provided by primary care trusts (PCTs), which were county-wide. But this government has replaced them with much smaller, GP-led clinical commissioning groups. In my view, the old PCT system – which had evolved over ten years – was working fine. This move has had no benefit at all and is putting patients at risk.
Under the new system, CCGs are given a budget by the Department of Health. Each time a GP refers a patient to hospital, the CCG has to pay the hospital a certain amount out of its budget. This approach is flawed for a number of reasons.
First of all, medical needs in different areas can vary, even if their demographic make-up is broadly similar. My county is split into two CCGs with similar demographics, and yet one keeps over-spending massively while the other always seems to have an under-spend. This is because the medical demands of the two areas are different.
The second reason is that CCG boards are left in a position where they have to make compromises in the face of shrinking budgets. My practice was told by the CCG board in April this year that, in the interest of balancing the books, we should reduce hospital admissions by 4% each year over four years. To achieve this, we were told to consult with colleagues every time we consider sending a patient to hospital. I’m fine with discussing patients with my colleagues, but am deeply concerned that considering money in my medical assessment will lead to patients being harmed.
In medicine, everything is done on the balance of probabilities. I, as a doctor, make a decision on whether to admit someone to hospital by weighing up the risk of not sending that patient against the benefit of sending them. If I have to include a consideration for cash savings in this assessment, I am pushed towards taking more risks.
One example is a patient who arrived at my practice with atypical chest pains. Taking into account his symptoms, as well as the CCG’s desire to save money, the doctor he saw sent him home. It turned out later the patient was suffering a heart attack. He survived, but treatment was delayed.
We are told of pilot programmes where practices have managed to reduce hospital admissions by up to 17%. But I think – and I would bet a lot of money on this – that admissions were not avoided, but delayed. These pilots only run over one year, after all.
What’s more, GPs are ill-equipped to manage CCGs’ budgets. They’re used to keeping track of their own practices’ finances, but this does not translate into planning area-wide medical services; it’s not their area of expertise, and they haven’t been given any training to do it.
CCG boards also suffer from conflicts of interest. GPs often own shares in private companies which are commissioned to provide health services for a CCG. The conflict of interest is obvious: I know of a case where the CCG lead on obesity runs an obesity clinic. Need I say more?
The way in which the country has been split into CCGs doesn’t make much sense, either. They haven’t been formed on the basis of cultural or geographical boundaries, but because particular GPs would rather work with some colleagues than others.
There’s also a growing drive towards obtaining medical services from private providers. GPs used to offer some ‘local enhanced services’ (LES): services ordinarily provided by hospitals, such as cervical screening. We have now been told by DH that these services should be put out to tender instead. We already have 200 providers involved in the NHS, with many more to come.
If GPs were to wake up to what’s really happening here, they would be up in arms. But the government has done it subtly and quietly: it has been splitting the NHS into smaller fragments because that way it will be easier to privatise. By lulling doctors in with a false promise that GPs would ‘control health care locally’, the government has managed to shift responsibility onto GPs, while preparing the NHS for privatisation – something I, like the vast majority of doctors, bitterly oppose.”