Peter Bailey: The King’s Shilling

David Cameron and Andrew Lansley assert that a large majority of GPs support their bill. Is it true? Where is the evidence? Is the profession lined up in willing support, eager to take on responsibility for managing the NHS through its greatest crisis? Perhaps we all took the King’s Shilling while in our cups in the taverns and only now are waking up to find ourselves press-ganged aboard a merchantman across uncharted seas in the government’s service.

Well, we did take the shilling. It has long been known that you train a killer whale to perform tricks by rewarding it with sprats rather than by poking it with a sharp stick. GPs respond to shillings in much the same way. The department of health has learned over the years that the best way to control independent general practitioners is to slice off some of their income and then make the GPs jump through hoops to get it back. No one likes having anything taken away, and the profession soon finds a way to earn the money back with maximum efficiency and minimum effort. GPs have had 50 years of negotiating over their contract and have got it down to a fine art. Or rather, the department of health has got the profession just where it wants it: well trained, docile, and responsive to sprats.

So when the Bill was first put before the public, PCTs were instructed to get GPs engaged in the process. How was that done? By slicing off some income and getting us to earn it back by joining commissioning groups. Almost all practices nominated a GP and a manager to go to the meetings and tick the boxes while the rest got on with the day job. Some of us volunteered willingly as we understood that the NHS faced a funding crisis and needed more GP engagement to develop sensible and cost-effective pathways for our patients to follow.

Lulled by our successes in getting top marks for achievement in the Quality and Outcome Framework points challenge, GPs let the bill gather momentum, with a distinct lack of critical engagement.

What you need in order to understand the purpose of the bill is perspective. GPs are nose to the grindstone dealing with the ever-growing expectations of their patients. It is hard to have an overview when you are struggling to keep your head up. Those in the crow’s nest whose job it is to look to the horizon have seen what is coming from some distance away.  There is a clear pattern. Successive governments have sought to achieve integrated primary and secondary care à la Kaiser Permanente, (a prominent USA healthcare organisation) having been dazzled by Alain Enthoven’s ideas in 1978 but they have failed to understand that if you introduce a free market you need stronger purchasers than providers. Every reorganisation has moved the pieces around the board but the balance of strength has tilted further and further towards the providers while confusing and destabilising the purchasers.

In the latest proposals, contained in the Health and Social Care Bill, one group of providers, we, the GPs, have been asked to take charge of an increasingly fragmented NHS with ever more autonomous trusts banging their drums and advertising their wares like market stall holders. GPs will be forced to get help from a rag-tag rump of PCT refugees or from privateer consultancies. Whether this further weakening of purchasing is mere bungling or a Machiavellian way of dismantling the NHS is not clear.

GPs are at last waking up to the wrong headedness of it all.

No, the majority of the profession does not support this bill. The truth is, the majority just haven’t thought about it much until recently. Now it is nearly too late. And Andrew Lansley is saying that your membership of proto-commissioning groups indicates support for his bill.

So why not get out there and tell your representatives in the commissioning groups, in the BMA and the RCGP and in Westminster what you really think? If necessary, give back the shilling.

(Thanks to Donald Light for the view from the Crow’s Nest)

Peter Bailey is a retired general practitioner, Cambridge