The Guardian: NHS reform: The GPs on the 'dark side'

NHS reform: The GPs on the 'dark side'

The government wants to put GPs in charge of NHS budgets to improve treatment. In Cumbria, they're already doing it. Sharon Brennan went to find out how it's working

• Sharon Brennan
• The Guardian, Wednesday 5 January 2011
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'People view me as being part of the dark side. They think it’s about saving money,' says Peter Weaving, GP (above). Photograph: Christopher Thomond for the Guardian

Rachel Robinson, 78, struggles to the door, walking stick in hand, to answer my knock. She has been "cut off" from her local community in Brampton, Cumbria, these last few months due to painful sciatica. She is now waiting for an MRI scan at Carlisle hospital, a scan that her local GP, Peter Weaving, was able to directly book for her. It is a small change that hides a radical shift in NHS power in the county. "Weaving's personal relationship to me is invaluable," says Robinson, and it is this powerful bond between GP and patient that the government is keen to harness and emulate nationwide.

In April last year, Cumbria's primary care trust (PCT) transferred its budget management powers to its GPs, enabling them to commission their patients' care. It is a move that closely echoes the government's ambitious plans for the NHS.

By 1 April 2013, the health secretary, Andrew Lansley, intends to eradicate PCTs and hand up to £80bn of the NHS budget to consortia of GPs across England to spend on commissioning the vast majority of NHS services, including maternity, mental health and accident and emergency hospital departments. In response to the health white paper consultation, the government last month said it intends to "press ahead immediately with pathfinders of GP consortia".

In 2006, Cumbria was in a "very bad place" according to Sue Page, 52, who had moved that year from heading Northumbria Healthcare NHS trust to become chief executive of NHS Cumbria. "There was an amazing amount of clinical disengagement and we had historic debt rising up to £36.7m," she explains.

In a bid to find a solution to years of overspending, Page introduced a Care Closer to Home strategy, designed to give Cumbrians a local health service that suited them while simultaneously balancing the PCT's books.

Page was to achieve this by putting the "docs in charge" of their budgets. Her rationale was that GPs, who are responsible for 90% of the public's contact with the NHS, were best placed to make difficult monetary decisions over treatment.

Four years on, this decision has seen 70% of the area's budget devolved to the doctors' control. This will rise to 97% by April. GPs are in charge of managing the budget for all prescription costs, running GP surgeries, commissioning services from local hospitals and budgeting for new local care plans, such as community nurses.

It is this concentration of power in primary care providers that has enabled Robinson to bypass a hospital consultation, the normal route to receive an MRI scan, significantly reducing her waiting time. According to Weaving, it is these "trivial things" that doctors have "waited years for" that will win them round to accepting budget responsibility.

Weaving, a senior partner at Brampton Medical Practice, is also one of six "lead GPs" who are each responsible for heading the GPs in the region within which they are based. These six come together in a formalised committee – the Clinical Senate – to debate commissioning issues that affect the wider county. Weaving works three days a week as a GP, dedicating the other two days to commissioning care in Carlisle, his region, or sub-locality as it is officially termed.

He admits it took "a lot of one-to-one conversations" to convince other doctors of his motives. "People view me as being part of the dark side. They think it's about saving money," he says. Although every Carlisle GP is part of his sub-locality, "probably about 10% or less are card-carrying enthusiasts", Weaver says, which means he has to step in to manage a practice's budget if it is not ready to do so.

Chris Corrigan, a partner at Brunswick House Medical Group in Carlisle, was one of those doctors who resisted the changes. For more than a year he was adamant he would not be involved in any scheme focused on reducing hospital referrals for budgetary reasons alone, but he was eventually won round to the scheme through the "credibility" of Page's leadership. "She proved her worth, she seemed pretty brave and prepared to take risks where other people were not," says Corrigan.

He is now involved in commissioning, leading a group of GPs to implement National Institute for Health and Clinical Excellence recommendations on hospital referrals, but remains clear that his "prime responsibility" is to act as his patients' advocate.

He questions whether GPs nationwide will be "responsible" with budgets that are at risk of an overspend, such is the strength of feeling for putting a patient's interests first.

Dan Golding, a partner at Nutwood surgery, Grange-over-Sands, shares Corrigan's concerns. Describing himself as a "coalface" GP, Golding has played no part in the Cumbrian reforms other than opting in to one of the county's six sub-localities. "I have some reservations. Say we get to this point in the year and there is no money left, where does the buck stop?

"I wouldn't be happy telling someone they can't have their hernia operation because there was no cash."

Evolutionary approach

Initially it was Page who championed clinical leadership, asking GPs such as Weaving with experience in managing budgets to "join the gang" in the early stages of implementation. Page admits that she would push doctors to take control but believes the process had "to come from the ground up", with the six localities taking shape from conversations on the street corner. "So over the four-year period, the gang of six became a gang of 20 became a gang of 50 and so on." She credits this evolutionary approach as the reason why there is only one practice in Cumbria opting out of the reforms.

The success that Cumbria has had with its commissioning model has instilled doubts among some of the region's doctors over Lansley's approach. He intends to compel GPs into taking up commissioning by refusing patient lists to those who do not comply. But Corrigan is unconvinced that enforcement will work, arguing that peer pressure is a more effective way forward. Following Cumbria's example, he believes it is "more crucial to identify lead GPs who are respected locally and to give them a position of authority."

Paul Corrigan, author of a Demos thinktank paper on the Cumbrian reforms, believes that the government's April deadline for all GPs to start commissioning services is a big problem. "As we get closer to that date there will be areas of the country that will not be ready and the government will then have to decide whether to extend [the deadline] or say to parts of the country, two years before a general election, we will make them do this even though they aren't going to do it very well," he says. He believes that Cumbria's reforms are comprehensive and have driven real improvements in patient services but credits the "very high-class local GP leadership" and the "time and effort [that] goes into helping those leaders to develop".

Weaving believes that "hard outcomes" are the best way of convincing unenthusiastic GPs that the new commissioning model works. In the 2009 transition year, when doctors made the decisions but the PCT approved the budget, Cumbrian GPs started offering minor hand operations from their surgeries at 20% less than the cost at hospitals. GPs are now in the process of introducing angioplasty operations in local hospitals that would allow Cumbrians to receive a single treatment immediately after they have had a heart attack. At present such patients have two less effective staggered treatments at a higher cost because they cannot reach fast enough the Newcastle hospital that offers angioplasty.

As Cumbrian GPs have placed their emphasis on providing primary care in their surgeries, hospital procedures have reduced. In Cumbria, the hospital's emergency admissions budget has been cut by 6%, a reduction of £6m in a single financial year, reflecting the fact that better community care is stabilising many patients with long-term illnesses.

Weaving admits that downsizing Cumbrian hospitals will be a "very sensitive thing for the public", but resources have been redeployed into creating new community NHS services as a result, such as setting up a team of home care nurses, with £6m of extra investment in 2009. He argues secondary care is often the "kneejerk response" for many GPs. "We were relying on a lot of overuse of our hospital bed base which was the most expensive healthcare. That is fine if you need it but doctors should regard it as a very scarce resource," he says.

Lack motivation

The British Medical Association has raised concerns that GPs will lack motivation if they are unable to improve patient care as a result of being burdened with current PCT debt. Chris Corrigan says it was Page's ability to get the strategic health authority to write off three-quarters of Cumbria's historic debt that won her the respect of the region's medics. As Golding puts it: "I'm much more likely to play ball if there is a carrot in it for me, but, more important, my patients". The government says consortia "will not be responsible for resolving PCT legacy debt that arose prior to 2011/12" but debt accrued after this period will be the GPs' liability when they take the reins in 2013.

Cumbria does not yet have all the answers, but the question is whether the government's plans for GP commissioning will make a real difference. "There are two ways this will go," says Chris Corrigan. "One is it will be very, very different to PCTs and it will work in 60% of the country and not in the rest. Or it will be very similar to PCTs in which case they would have gone through an enormous set of changes with no real difference".

Robinson is relieved that her painful condition may be resolved more quickly due to the commissioning reforms in Cumbria, but she remains pragmatic about the wider forthcoming NHS funding changes. "In a way it's all of our problems. We expect so much in terms of treatment and what is available and I know very well that it is not a bottomless pit."