Who is commissioning who?

A Department of Health spokeswoman said: “Our reforms will indeed mark a new era for the NHS – one where patients and clinicians are at the heart of the service. Our reforms aren’t an option, they are a necessity….” Guardian 19.11.2010

The perception most GPs have is that no amount of appeals to the Department of Health or the Commons Health Committee will change what is being described as a “done deal”. The fear is that if GPs don’t become the commissioners, private corporations will be bought in to do the commissioning for them, and it is this fear which is driving many to go ahead with the Health White Paper proposals they despise.

“NICE is accountable to the public,” Lord Crisp – the former NHS chief executive – advised Parliament last week. “What we don’t need is to import American style private sector rationing where individuals find themselves the victims of decisions made in private by individual insurance companies where nobody is accountable.” Health Service Journal

What is more, in the not too distant future, uncapped university fees will lead to newly qualified doctors with unprecedented debts who will then be easy prey for insurance companies who will offer them a salary and structured debt repayment they’ll find hard to refuse…but at what cost?

According to a thought provoking article by the eloquent David Loxterkamp, The Dream of Home Ownership

In the summer of 1984, no primary care physicians were employed by our local hospital. In the past 5 years, physicians who left or retired were all self-employed; contracted physicians took their place. The medical staff is now mostly on hospital payroll. This trend is neither isolated nor inexplicable. Graduates of private medical schools carry a median debt of $180,000; the burden of public school graduates is only slightly smaller at $145,000.00.3 Large corporate and hospital-owned systems are poised to invest heavily in recruitment incentives, loan forgiveness programs, higher salaries, and freedom from administrative worry. But at what cost for primary care?

The culture of group practice was studied in 2003 by Curoe, Kralewski, and Kassi.8 They found that 2 factors—size and ownership—were pivotal. The authors surveyed 547 primary care clinicians from 148 Midwestern clinics and analyzed their data using contingency and complexity theory. They found that clinics owned by private or hospital-based systems had “less organizational trust, less identification with the group practice, and less collegiality among physicians.”

We can expect the end of independent GPs. We will become the salaried employees of corporations and the bottom line will be profits, not patients. Medicine will be protocol driven with a loss of clinical freedom and less patient centred care, less commitment to our practices and our patients, and the loss of trust upon which our work depends.

As Dr Loxterkamp concludes:

Together we must demand a broader, more-farsighted, and compassionate view of the business of medicine. I am reminded here of another Christmas classic, and words uttered equally to the point:

“Business!” cried the ghost, wringing its hands again. “Mankind was my business. The common welfare was my business; charity, mercy, forbearance, and benevolence, were, all, my business. The dealings of my trade were but a drop of water in the comprehensive ocean of my business.”1Dickens, C. A Christmas Carol. Boston, MA: The Atlantic Monthly Press; 1920:33.

As we indenture our labor, mortgage our homes, lease our cars, and live on borrowed time, let’s at least own our conscience and the decisions about whom we serve. And work to create systems and structures that dignify and promote human relationships—the very foundation of primary care. We cannot afford to relinquish the dream. Ownership, by which I also mean a sense of commitment and empowerment, begins at home, in the medical home, at the heart of medicine.

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