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The NHS White Paper: an uncertain future for primary care

Marilyn Eveleigh
Consultant Editor

The new coalition government has announced the changes it proposes will make the NHS more efficient, more accountable and ensure it meets patient needs; and I love the rhetoric - how can anyone not applaud such altruistic and laudable goals? The public are the patients, the "customers" - and as they are paying, they want the same.

Is this NHS reorganisation any different from all the others? It has been said this will be THE most radical of all. There have been many "reorganisations" within the last five years. Some had a tinkering around with the legislation: the amalgamation of more than 300 primary care trusts (PCTs) to the present 152 is one that NiP readers will have felt. Some were softer, with agreed "new ways of working", such as the separation of the commissioner and provider roles of the PCTs.
Some messages are the same, but louder. Bureaucracy and management will be reduced by 45%. The 10 Strategic Health Authorities are to go. Though recently reconfigured, PCTs are to be abolished. Clinicians will lead the change and patients will
be central to the process - "no decision about me, without me".

Determining what services patients need will be made by the 36,000 frontline primary care GPs who "know their patients". Commissioning of healthcare will be done through 500-600 consortia, made up of around 80 GPs in each. Bigger than GP fund-holding in the early 1990s, with 90% of the NHS purchasing budget of £70bn, and fewer constraints from where they can buy healthcare. A National Commissioning Board will determine specialist services, pharmacy and maternity care.

How and where services should be provided will be decided by empowered clinicians - aka doctors and nurses. This will not be a monopoly by GPs but will be in
partnership with specialists in hospitals to ensure pathways meet patients' needs.

Who can provide will be thrown open to an even wider private market; market competition is believed to drive up quality and drive down price - just what the taxpayer wants. At the present time only half a percent of NHS services are provided by non-NHS organisations. This will change. Any willing provider, private companies and social enterprise not-for-profit organisations will be invited to tender for NHS services. Nurses could set themselves up as new independent providers of NHS care.

Will GPs want this leadership and decision-making role? Can doctors juggle clinical roles and strategic management of the NHS? Are medics skilled in management and this level of responsibility? Practice-based commissioning groups where GPs commission local services have not been universally successful and have not had buy-in by all GPs. Some think this new coalition proposal is being forced on GPs - and the risks are high. There has been little explicit inclusion of clinicians such as nurses, pharmacists and other professions allied to medicine so far. Might this lead to fractions among the family of clinicians?

In my experience of reorganisations (or restructuring as it less dramatically known) there is an initial frenzy of activity at higher strategic managerial levels that frontline staff are not even aware of. New terminology, new titles and logos, new plans and new targets take time to filter down through the ranks. During the process, patient services are kept going though the wind of uncertainty blows through the organisation. The NHS is the world's third largest employer, claiming 9% of GDP and providing healthcare free at the point of delivery. The whole population will feel the impact of this reorganisation.

This uncertainty throws up a variety of responses and behaviours in healthcare staff. For those who have been through a number of disappointing changes, pessimism and an unwillingness to engage may be evident. For those who have fresh ideas and unblemished ideals - your time has come!

Become engaged in the consultation, consider opportunities to further your professional influence and be imaginative about redesigning patient services. GPs will need support to spend wisely when there are no additional funds. They will need managers to make the changes they determine actually happen. They will need nursing leaders and nursing competencies to satisfy diverse public needs.

Stay on the NHS rollercoaster ride ahead, and expect highs and lows along the way - you can be sure it will slow down one day. What will emerge is the big question.

Welcome the opportunity or just hope to survive, your choice.

Your comments (terms and conditions apply):

"The UK public will need to alter their mindset. Supportive services which have not been seen as essential, will become private, and the patient/client/consumer will have to pay. They will learn to live with this or they will flounder with minimal information and support. Gone are the days when each patient was the same as the next as regards the provision of service. We have skill mix in primary care, this will be extended. Community nurses are already waiting to see if they still have jobs while managers fret about their own futures. The biggest challenges are about to arrive. Expect American healthcare providers to expand their hold within the UK. Nurses, health visitors, there are opportunities for you if you feel up to the challenge. For all those who have lived with 'use your initiative when I permit it.' This is a BIG opportunity to redesign a service, in which you lead" - Deirdre Budd, Amsterdam