Taking care of budgets

On 1 April the National Health Service took another step closer to being fully privatised. On that day, 211 clinical commissioning groups (CCGs), headed by general practitioners (GPs), took over responsibility for the majority of the NHS budget in order to ‘organise’ local health services, replacing 151 primary care trusts (PCTs). CCGs now have responsibility for commissioning (buying) services, such as community healthcare, maternity and children’s services, emergency care, routine, planned hospital care, older people’s and rehabilitation services, mental health services, and care for those with learning disabilities, among others.

The government claimed that this part of its health ‘reforms’ will mean services will be decided by those ‘closest to patients’ who understand local needs best. However, in doing so it ignored the wishes of the very people it was asking to run the commissioning groups. The vast majority of GPs opposed these plans which were part of the Con-Dem government’s Health and Social Care Act (2012).

Last year, GP Helena McKeown resigned her role as commissioning advocate saying, "I feel very disillusioned by the way clinical commissioning is going so I cannot remain a clinical commissioning champion… If we were truly able to commission to make best use of resources and not tie ourselves to constitutions that interfere with our role as a GP, I would be proud to be asked to continue. As it is I can do more by resigning to expose what GPs are being set up to do: in the first instance, to fail to keep within budgets devolved at practice level; in the long term, to undermine our unique role as patient advocate". (British Medical Journal, 11 September 2012)

The British Medical Association (BMA) also campaigned against the changes. All but one of the 26 royal medical colleges opposed it, as did all major health unions. Dr Clare Gerada, of the Royal College of GPs, stated that she felt the plans would lead to greater fragmentation of already poorly integrated NHS services.

CCGs can pick and choose which services they provide in their areas creating even more of a postcode lottery than we have now. Gerada also warned of the potential increase in health inequalities between rich and poor. This will be the case because, rather than be simple commissioners, CCGs will allocate services and be forced to decide which services to deny their patients in a cash-strapped NHS facing further government cuts. The amount of money spent in the reorganisation is uncertain but undoubtedly runs into the millions.

Most GPs also see commissioning as a conflict of interests. They traditionally see their role as an advocate for each individual patient who comes to them, informing them of the best care to meet their needs. GPs are not generally involved in public health or planning health services for a whole population. They realise that holding the purse strings would mean their concern about balancing the books might conflict with their desire to do the best for their patients. They know that it would jeopardise the trust patients have in them if patients are aware about this dual role. Imagine trying to tell a patient you don’t think they need referring for a hip replacement when they know full well you are embroiled in cutting costs in the local NHS budget!

Because most GPs have been repulsed at the idea of having to be commissioners they have avoided volunteering for roles on the CCGs. This has left the way open to those GPs who tend to agree with the idea or may even have something to gain from being able to influence what health services are commissioned. Shockingly, a recent survey by the BMA found that just over a third of GPs involved on CCG boards are also members of profit-making private health organisations. As most GPs nationally do not have private health interests this is clearly disproportionate. These GPs could be commissioning services from the private providers that they also benefit from financially.

GPs are meant to declare a conflict of interests and remove themselves from voting in this situation. But being on a CCG will give them inside information regarding what service areas are being looked at. Potentially, it puts their private organisations at an advantage, being able to position themselves better when bidding for contracts. In one CCG the majority of the executive board had an interest in an out-of-hours provider, meaning they would all have to sit out of voting over issues related to this service. How can decisions about health care be made on that basis?

This disgraceful conflict of interests is an example of how health changes will inevitably lead to increasing the influence of the private sector in our health care. While most GPs have distanced themselves from the direct commissioning role in CCGs, worryingly, many of those running them see no problem in the idea of organisations profiting from health care and the private sector undermining the NHS as we know it.

A further concern is the possibility that, in the same way as some GP practices have been taken over by private companies, GPs struggling to balance their commissioning role with their ‘day job’ may hand over the running of CCGs to organisations like Virgin and Care UK.

There are exceptions, though. Haringey CCG, in north London, has amended its constitution to make it more accountable and transparent to the public, and only to invite providers to bid competitively for contracts to run services where ‘necessary or appropriate’. Contractors must be ‘good employers’, meeting tax and national insurance obligations, and must not have committed offences or be guilty of tax avoidance and offshore schemes. You would think this should all go without saying!

They are obviously well intentioned and are trying to protect the NHS from the big private health companies. However, these minor amendments do not go far enough. How can the public have confidence that CCGs are making decisions in their interests rather than those of the private sector and, potentially, GPs’ own financial gain? Both the BMA and the Royal College of GPs have raised concerns and stated that GPs should either reconsider their position on the CCG or within the private organisation, but should not continue to do both.

Even more disgusting is the fact that GPs are blocked from raising concerns about local health care by the CCG constitutions they signed up to, it was revealed by Pulse, a GP magazine. This is in spite of government claims that gagging clauses are unacceptable – following the scandal at Mid Staffordshire hospital, where the hospital trust was investigated over higher-than-average death rates. It was found to have been negligent in many areas of patient care, yet a number of staff who had worked there had been prevented from speaking out by clauses in their work contracts. Nonetheless, local agreements for more than 200 practices still contain such clauses, preventing GPs speaking out without the board’s approval.

It is important we make demands upon CCGs to be more accountable and to commission NHS services, not private ones. In reality, a far greater transformation of the way the NHS is run is needed. The first vital component is that NHS funding is increased to meet needs. What the population’s health needs are can only be worked out by bringing together democratically elected representatives from different healthcare professionals, via their trade union organisations, plus members of the wider public, to prepare accurate assessments. Those planning health care should not be allowed to profit financially from doing so. The ending of costly private finance initiative contracts would save the NHS millions. Reintegrating renationalised services would also see a more efficient NHS and be the only way of ensuring all have access to treatments on the basis of need not postcode or the ability to pay.

A GP in North-West England