We write as General Practitioners working predominantly in City and Hackney PCT with concerns about the Health White Paper “Equity and Excellence: Liberating the NHS”.
We believe that the proposals will seriously compromise the care our patients need. Our main concerns are:
- No evidence and no mandate
- Fragmentation of care among a myriad of competing providers.
- Profit as a key criteria for success.
- Threat to continuity of care for our most vulnerable patients.
- Increased conflicts of interest for doctors treating the sick at the same time as controlling rationing of services.
- Restriction of patient choice.
- Cuts in service.
No evidence and no mandate
In our view, the White Paper proposes the break up of the NHS based on an ideology that market forces will result in efficiency – a hope that lacks any evidence. Even the last Health Select Committee reported that 20 years of commissioning in the NHS was a failure and had only led to increased transaction costs estimated to be 14% of the total NHS budget. Changing who does the commissioning rather than abandoning the concept does not seem logical.
Can we also remind you that your constituents did not have a chance to vote on this as it was not in any manifesto – in fact the Conservatives said there would be no top down reorganisation of the NHS?
We have many patients who have confidence in and familiarity with their local hospital that currently provides a comprehensive range of services. The White Paper will compel us to commission services from ‘any willing provider’ which will lead to this comprehensive care being fragmented. Local NHS hospitals will be forced to compete with private providers and because EU rules state that no preference can be given to NHS providers, any GP consortium which gives their local hospital preference could be open to legal challenge. Consequently NHS hospitals will have no choice but to concentrate on profitable departments and close the others in order to remain competitive. Many of our patients and their families have mobility or financial difficulties with private transport. They simply will not be able to cope with being sent to hospital A for the cheapest cardiac investigation, centre B to see the most efficient cardiologist, while league table topping centre C deals with their diabetes. There is also the risk of each centre being unaware of what the other is doing.
Private providers with NHS funding are not new. The previous government encouraged private providers to compete for tenders and so we already have some experience of what is in store. Where we work MRI scans can be ordered by GPs from a private company. While the scans are usually done and reported quickly, in many cases they have to be repeated by the local hospital because the results cannot be accessed or adequately interpreted.
Profit not quality
According to the Health White Paper, all providers will be expected to make a profit. Hence there is a serious risk that the best care will be diverted to those people who are most profitable to treat, not those who need it most. A fit and healthy young person with a single medical condition can be treated quickly, efficiently and “profitably”. But our patients with long-term conditions cannot be cured. Their illnesses cannot be managed with efficient medical interventions. They need expensive, often unpredictable, ongoing hospital and community care. Health-care based on profit will fail these, our most vulnerable patients. According to the WHO Committee on Social Determinatants of Health, “it is the public sector rather than the market place that ensures equitable distribution of resources” Markets are not only inequitable but also unacceptably expensive: “The most important reasons for the uniquely high costs of the US health system are its commercialization and the effects of business incentives on the provision of care. The US has the only health system in the developed world that is so much owned by investors and in which medical care has become a commodity in trade rather than a right.”
Care of the vulnerable
Our patients who need the greatest care have complicated mixtures of medical, social and psychiatric conditions. For example, it is impossible to look after someone’s diabetes effectively if you do not also understand their dementia and their social circumstances. GPs need to retain responsibility and care needs to be coordinated. Multiple competing providers will make this far more difficult.
Conflict of interest
There are already conflicts of interest between our duties to our patients and our duty to the NHS because of the target-based criteria which govern our pay. For example we are paid according to the proportion of children in our practice we vaccinate. GP commissioning as proposed in the Health White Paper will hand 80% of the NHS budget to GPs forcing us to consider the cost of every medical decision we make on behalf of our patients. Patients will rightly be asking us how much their care is being compromised in order to balance our books. In the United States, where the commercialisation of medicine exists in its most extreme form, the American medical profession has lost public support faster than any other professional group. 
Restriction of choice
The White Paper promises even greater choice for patients. Prior to 1990 a GP could refer their patient to any hospital or consultant within the NHS. Since then, as a consequence of market reforms choice has been used, not for the benefit of patients and doctors, but to stimulate competition and convert the NHS into a market. When asked about choice patients say that it is more important for them to receive continuity of care with a doctor they know, and quality comprehensive care at their local hospital. Older patients, those with greatest health needs express this most strongly. The type of choices proposed in the Health White paper may be most attractive to the young, mobile, savvy and well-educated but are illusory for those who need health care most of all. They are also very often, the poorest and least educated and therefore tend to be the least vocal in representing their own interests.
The government implies that commissioning decisions will be made closer to the patient because it is GPs who will make them. In fact the converse will be true locally. Commissioning consortia are to cover populations of between 100 and 750 thousand. The BMA have advised that for reasons of financial risk they should cover at least 500,000 – this is larger than Haringey and Hackney PCTs together (both around 200,000). The consortia do not seem to need any democratic accountability to local populations and may only lead to a return of the postcode lottery as different areas decide on different spending priorities.
Cuts in service
The NHS has already been told it has to find £20 billion in efficiency savings by 2014. The white paper proposals are the largest reorganisation the NHS has had and estimates are that they will cost £3 billion. We know frontline services are continuing to be cut, whatever the rhetoric. NHS Direct is under threat, various PCTs have announced service cuts e.g. rationing of joint replacements (Hertfordshire PCT), reduced length of stay for terminally ill patients (Sutton and Merton PCT) and the closure of nursing homes (Peterborough PCT).
The government has no mandate to introduce these changes and has left little consultation time. The proposals in the White paper will destroy the NHS as a public service providing comprehensive care for all on the basis of need.
Dr Helen Andrewes (Wandsworth PCT)
Dr Sven Baumgarten
Dr Lucy Carter
Dr Deborah Colvin
Dr Jenny Darkwah
Dr Phil Delahunty
Dr Chris Derrett
Dr Rhiannon England
Dr Adam Forman
Dr Ali Gibb
Dr Jonathan Gore
Dr Josephine Heyman
Dr Victoria Holt
Dr Anu Kumar
Fiona Leggett Practice Nurse
Dr Michael Leonard
Dr Gary Marlow
Dr Jens Rubach (Tower Hamlets PCT)
Dr Melissa Sayer
Dr Julie Sharman
Dr Carmel Sher
Dr Ruth Silverman
Dr Nicki Singer
Dr Ann Soloman
Dr Jonathon Tomlinson
Dr Gary Wych
 World Health Organisation Social determinants of health http://www.who.int/social_determinants/en/
 Health Care: The Disquieting Truth Arnold Relman New York Review of Books