Commissioning: further issues - Health Committee Contents

Written evidence by the Medical Practitioners' Union (CFI 09)


MPU, founded in 1914, is a small group of doctors (compared to the BMA) currently mostly GPs in deprived areas. MPU merged with another trade union that has resulted in becoming part of Unite. We participate in the representative machinery of the medical profession through agreements reached with the BMA in 1950. As part of the Health Section of Unite MPU's policies are informed by other professional groups, particularly health visitors, sexual health workers, mental health and school nurses. It has a track record of influencing national policies such as: the GPs' Charter, Junior Doctors' hours, and of influencing the medical profession - exposing racism in the profession, the vulnerable position of sub-consultant grade doctors, campaigning for a salaried option for GPs and for better health services for asylum seekers.

Of particular relevance is that MPU produced proposals for locality commissioning (1991) which became Labour Party policy in 1992 and the policy of the BMA by the mid 1990s.


(References: "Clause ..."' refers to the Bill; "IA ..." refers to the Combined Impact Assessment. Other references will be supplied on request)

1. Context: The National Health Service is not perfect but has improved particularly since its funding was increased. It had its highest patient satisfaction rating recently. Its outcome figures do compare well with other health systems in spite of government assertions to the contrary. The NHS provides access to health care rated as the best in the developed world.

Whilst it is possible to agree with elements of the Bill, we oppose the Bill as a whole because of the creation of competitive markets, the powers of Monitor, the wholesale dismantling of organisational structures, the privatisation of NHS assets and the conversion of Directors of Public Health into local government officials with perceived loss of their important independent voice.

The basic ethos of the NHS may not be directly undermined by the Bill but indirectly the "free at the point of use" principal could be undermined by the uncritical adoption of market principles. As profits become the bench mark of "good health services"' some services could be seen as not cost efficient merely because they are complex and expensive rather than inefficient.

Marketisation and commodification of health services reduce the high ideals of the NHS to that of simple trading. The ethos of the NHS and of those who working in the Service are crucial to its success and mirrored by the high value which the population ascribe to it. Knowing the price of everything and the value of nothing sums up this concern.

The experience of Independent Sector Treatment Centres (ISTCs) is that they offered services (often at 11% above NHS Tariff) to patients with uncomplicated medical histories ('cherry-picking) leaving the NHS to deal with patients with complex, multiple diagnoses.

The evidence from PFI projects is that they are more expensive than publicly financed builds, are poor value for money and distort the funding allocations to PCTs with PFI projects.

The Health Services of Wales, Scotland and Northern Ireland have not introduced the purchaser-provider split nor competition as a drivers for cost efficient, quality services.

2. No democratic mandate: the reorganisation of both the provider and commissioning side was five years in the planning according to the SoS but barely mentioned in his Party's Manifesto and specifically ruled out in the Coalition's Agreement - no top down, major reorganisation of the NHS. There should be trust between the people and its government - such trust has been jeopardised with regard to the future of the NHS in England.

3. Commissioning is defined by MPU as: the process of gathering and analysing the wants and needs of a population, identifying the services required to meet those needs and of monitoring those services and their outcomes as they are delivered.

4. There is nothing against and everything for the involvement of GPs and other professions in the commissioning of care. There is however no need to abolish PCTs or SHA to achieve this, nor to establish competition within the provider setting.

5. Privatising the Commissioning Function: the abolition of PCTs and SHA to be replaced by GP Consortia opens the door to private sector involvement in the commissioning process. This is of course government policy and MPU is totally opposed to it. There has been confusion as to whether GPCCs will be NHS Bodies (Clause 6 1E (1)) - they should be.

GP Principals are independent contractors to the NHS under one of three contractual arrangements: General Medical Services (GMS) a UK wide, national contract; Personal Medical Services (PMS) a locally held contract with a PCT and; Alternative Personal Medical Services (APMS) which is a proper commercial contract with a PCT. GMS and PMS are the norm and GPs and their staff have access to the NHS Pension scheme and regard themselves very much as "part of the NHS".

APMS contract holders do not have to be GPs and have fully commercial contractual arrangements with PCTs. They are more distant from "the NHS family". The GPs working in APMS are usually salaried to the company and are usually not GP Principals.

Two or more APMS practices could form a "private" Consortium with confused allegiance to either private employer or NHS, yet with access to NHS funds. As with all Consortia it can write its own constitution, raising issues of accountability and conflicts of interest.

6. Price competition within the NHS as indicated by supplementing national tariff with a "maximum price" (Clause 103 and 104), has been shown to lower the quality of health care provided. Improving the quality of health services should be by sharing good practice and outcome data, thereby using peer pressure rather than market competition. This method has been successful in rationalising prescribing by GPs and would work in a similar way for inappropriate GP referrals.

Recent "clarifications" by the SoS that competition will be based on quality not price will remain unconvincing whilst "maximum price" is on the face of the Bill and whilst Monitor's role is specifically stated as promoting competition (Clauses 52 (1) (a) and 63 (1) (c)) and enabling easier entrance to and exit from the "health market" (IA B106 and 112).

We would ask for the evidence that market competition improves health outcomes. (The Impact Assessment rests its case for the success of market competition on examples from new car sales, replica kits, the air travel industry and opticians). We question the current rhetoric that investment over the last 10 years had not improved health outcomes. There are improving outcomes for stroke management, surviving heart attacks and for cancer services which have not been quoted by the Government.

7. If the Any Willing Provider policy (AWP) is pursued as currently envisaged GP Commissioning Consortia (GPCCs) will actually do very little commissioning as defined above. Services are likely to be commissioned as follows:

(a)  Special Commissioning by NHS Commissioning Board

(b)  A&E, ITU and so on - no tendering as they are likely to be located at the local hospital (whether NHS or privately run). Any reconfiguring will have to be done at a supra-Consortia, "regional"' level.

(c)  Elective Services - AWP will be selected by the patient with GP support from a national list perhaps trimmed to more local providers

(d)  Long term conditions (eg diabetes, heart disease) "off the peg" packages of care will be designed by providers and offered to Consortia. It is likely that any "tweaking" of the package will only be possible at the margins since providers will want to minimise different services for different (neighbouring) consortia. This "provider dominance" is commissioning the wrong way round and leaves the tail wagging the commissioning dog. If led by the private sector and uncoordinated it risks further weakening the comprehensive nature of current NHS services.

Consortia are the bill payers for most of these services and will have limited choice over providers. The patient chooses elective care not the host consortium. The SoS has recently said that competition rules will not apply if the Consortium can show their decision is in the best interests of patients. Once the Bill is law the present or any future SoS could change this interpretation.

How will GPCCs manage demand with such limited control over service provision?. Demand management of appropriate GP referrals has historically proven difficult. As noted above, peer pressure could reduce inappropriate referrals.

8. The AWP policy is likely to be detrimental to NHS hospitals and to the provision of comprehensive acute services. Commercial providers have to date provided straight-forward procedures only - hip replacements, hernias and cataracts. The Impact Assessment makes explicit that there should be easier entrance to and exit from NHS provision and that competition between providers should be stimulated (IA B4). As private providers take more procedures from NHS hospitals the following may result:

—  Acute hospitals rely on "cross-subsidies" to support over tariff services from services provided under tariff. Less income to NHS providers leads to financial instability and pressure to increase non-NHS income; for example, exploiting the removal of the cap on earnings from private patients (IA B72) resulting in longer waiting lists for NHS patients (IA B156).

—  A&E and ITU unable to call on a complete range of services 24 hours a day if some departments have "failed" and closed (IA B149).

—  NHS left with more complex (IA B54) and expensive case mix due to "cherry-picking".

"Designated Services" as laid out in the Bill (chapter 3) will attract a premium payment (Part 3 chapter 7) from the provider and so there will a disincentive to designate services. Again A&E may not have a full range of services to call on 24 hours a day unless all relevant services are "designated", the direct opposite of the Government's intention to apply the rigour of the market.

9. Postcode lottery of services: Consortia are to have autonomy, can construct their own constitution and decide which services will and will not be provided for their patients. Patients in neighbouring Consortia could therefore receive a different menu of services provided to different service specifications. Whilst adapting services to local need is acceptable this policy tends to remove "National" from the NHS and puts at risk the equitable provision of services for the English population as a whole.

10. Fragmentation of Community and Primary Care Services: The NHS delivers care in teams - obvious in the hospital setting but less so in the community. During the 1980's primary health care teams (PHCT) were common - health visitors, midwives, district nurses, GPs, practice managers and often social workers. The move away from practice alignment of community staff and increasing work load as more services are provided in the community, has led to the decline of PHCTs and poorer coordination and integration of services (IA B44). The best primary care relies upon good systems, good relationships between colleagues and, crucially, trusting and long-term relationships with patients. Any attempt to re-introduced PHCTs to promote integration of services will be hampered by multiple, community providers competing for business rather than cooperating for care.

Multiple providers in competition with each other has already proven problematic for primary care as residential care services have been privatised - one company employing the staff, another providing care packages to residents and community staff who now have little contact with the practices serving the residents.

11. Conflicts of Interest:

—  GPs and/or private companies as both commissioners and providers

—  GPs having to consider the Consortium's budget versus the needs of the individual patient coupled with rewarding practices for referring less (Clause 23 223L). This fundamentally distorts the trust embedded in the doctor-patient relationship and the GP's role as patient advocate.

12. MPU also has concerns similar to those raised by other groups and organisations:

—  the haemorrhage of talent from PCTs and SHAs at a time of massive reorganisation;

—  resources diverted to reorganisation rather than patient care;

—  costs of redundancy pay, the reorganisation itself and rising transactional costs;

—  risk of organisational dysfunction or collapse;

—  lack of evidence that the new system will benefit patient care;

—  weak accountability and democratic structures proposed; and

—  knock on effect on teaching and training as private sector absorbs more trained staff.

1981 to 2009 GP Principal in Edmonton, North London.
1982 to Date Member Enfield and Haringey (now Enfield) Local Medical Committee
1982 to 2004Member of various NHS Bodies representing Enfield Local Medical Committee or Edmonton GPs: Enfield and Haringey DHA, Enfield DHA, Edmonton Primary Care Group, Enfield PCT's Professional Executive Committee
1992 to 2003 Founding and Executive member of National Association of Commissioning GPs (which later became the NHS Alliance)
1996 to Date Member of General Practitioners' Committee of BMA (representing MPU)
1996 Author/editor: GP Commissioning: an inevitable evolution (Radcliffe)
2003 to Date President, Medical Practitioners' Union - Unite

Dr Singer is not a member of a Political Party but contributes indirectly to the Labour Party via Unite's political levy.

February 2011

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Prepared 5 April 2011