Lansley's deadly prescription

The debate over the government's controversial white paper, laughably entitled Liberating the NHS, is beginning to widen and the scale of opposition to many of its core proposals is becoming clear - even among the group who appear to have most to gain from it.

GP magazine found less than one in five of the 300 GPs who responded to a poll believed that the changes would improve patient experience or the funding of primary care services.

Twice as many (41 per cent) feared a fresh "postcode lottery," while 71 per cent expected the scrapping of primary care trusts and strategic health authorities to lead to an increase in private-sector involvement in commissioning.

No wonder one of the leading apologists for the scheme, Dr Michael Dixon of the NHS Alliance, has issued a rather desperate appeal for GPs not to turn their backs on the government proposals, claiming that it would be "utterly disastrous" if they did not "embrace the white paper and make it work."

It seems that even he has seen that the tide of opinion is flowing against Health Secretary Andrew Lansley's plans.

What a pity the BMA national council assumed instead that its members in primary care would want to go along with the white paper, and voted for "critical engagement" rather than join the opposition.

Of course Dixon has got it the wrong way round. The real disaster would be for GPs and their organisations to allow themselves to be cynically used by the government to push through proposals which will have far-reaching and negative consequences for patients as well as for the NHS and its one million employees.

Like BMA chairman Hamish Meldrum, Dixon simply buries his head in the sand and ignores the massive £20 billion of cuts that are written in to the white paper, claiming that commissioning is "an opportunity to influence our own destiny."

But the scale of these "efficiency savings" guarantee that the consortiums of GPs established to spend £80bn in commissioning budgets will become little more than rationing committees, choosing which services will be cut and which sections of patients should lose out.

This is not "liberation" for the GPs or their patients - it's a capitulation to the Con-Dem government.

Indeed there is no guarantee that the Con-Dems could carry out their plans if the NHS Alliance, the Royal College of GPs and the BMA simply took a firm stand against the marketisation and privatisation of health care that are implicit in the white paper.

Until a few weeks ago the BMA was conducting just such a campaign, now sadly sidelined as it struggles for influence with Lansley. Its leaders seem to have wrongly concluded that they are in a much weaker situation than they are really.

Even supporters of Lansley's plans have made clear that the endorsement and involvement of GPs is essential if the plans are to be carried through. So a united front of doctors, along with the health unions which have already declared themselves against the proposals, could force Lansley to think again.

By contrast, if the GPs wind up going along with these proposals, they will be cynically used as the scapegoats by Con-Dem ministers, and have to take the blame for unpopular cuts, closures and policies which will in effect have been imposed upon them.

Of course Lansley chose soft targets when he singled out the primary care trusts and strategic health authorities for closure, and cunningly pushed the right buttons with some frustrated GPs when he suggested they take over the commissioning role. It would be hard to find anywhere else in the public sector where the possible loss of 60,000 jobs created so little anger or militant resistance.

Few primary care trusts or strategic health authorities have done anything to endear themselves to local communities - many of which have been systematically patronised and ignored in spurious "consultation" exercises - or to the many sections of staff in NHS staff in provider services who have been on the receiving end of some of their decisions.

So it's true that nobody could build a credible campaign simply to defend primary care trusts or strategic health authorities. But by no means everything they have done has been without value, nor are all their staff pointless bureaucrats. Nor is it true that simply scrapping them will necessarily produce anything better.

Subdividing 150 primary care trusts into 5-600 GP consortiums, each comprising 80-100 GPs, will inevitably raise the question of how these are to work either singly or together.

It seems certain that many of them will resort to rehiring staff made redundant from primary care trusts - or spend even more to bring in private management consultants to do much of the administrative work that still needs to be done. And with NHS providers having to negotiate with more separate groups of "purchasers" the total bill for bureaucracy will not fall by much if it falls at all.

But the new bureaucracy will be even less accountable than the primary care trusts.

The white paper says nothing on how consortiums should be formed, who will approve them or how they might be held locally accountable for their actions.

What is to stop the better-resourced GP practices, which tend to be in the wealthier areas, from taking the lead - raising potential problems of unequal access to care and a lower level of provision for patients in deprived areas?

The white paper does not even require GP consortiums to work with other consortiums, or take any wider view beyond their own local catchment population.

So neighbouring consortiums could well take counterposed decisions on commissioning care, which could result in the collapse or withdrawal of local hospital or mental health services, reducing access for patients and widening the inequalities from one area to another.

Perhaps worst of all, there is absolutely no evidence that these expensive, experimental reforms - the biggest-ever privatisation of health care anywhere in the world - could deliver the promised improvements for patients.

It's all looking like a mess waiting to happen. And with even top-flight fans of market reforms and privatisation like former Department of Health director of commissioning Mark Britnell and the Conservative Party's Bow Group questioning the viability of the new consortiums and the ability to generate any of the required savings, the cost of implementing the white paper (upwards of £1.7bn) seems like a classic waste of money much better spent on patient care.

Similar methods have been tried before - and failed. The Tory experiment in GP Fundholding in the 1990s cost hundreds of millions in bureaucracy and resulted in tens of millions in budgets for patient care remaining unspent in GP practice budgets while waiting lists rose and local hospital trusts faced deficits.

More recently new figures show that much smaller-scale experiments in "practice-based commissioning" under new Labour, involving volunteer GPs in an expanding NHS, still wound up costing much more than they saved.

So it's no real surprise that the most sensible GPs seem to be pulling back from involvement in a doomed project that could leave them taking the blame for every local problem.

What we need now is a bold, active and high-profile campaign from the health unions to push this issue right up the agenda and give hope to all those who fear the side-effects of Lansley's deadly prescription.