three - Doctors in the driving seat? Reforms in NHS primary care and commissioning

Summary

Introduction

After a protracted parliamentary process, on 27 March 2012, the Health and Social Care Bill of the Coalition government gained Royal Assent to finally become the Health and Social Care Act 2012. This latest National Health Service (NHS) reform taking full effect in April 2013 introduces a radical reorganisation of the way NHS services will be commissioned and establishes a regulated market in which ‘any qualified provider’ from the public or private sector can compete for the provision of NHS services. While the NHS continues to be publicly financed and free at the point of use, the Act entails an accelerated move to a fully functioning market for health care in England. Notably, it claims to put General Practitioners (GPs) ‘in the driving seat of the NHS’ (GP Online, 22 July 2010) by transferring the responsibility for most NHS commissioning to them.

This chapter discusses the main changes to the organisation of health care commissioning and delivery in England as a result of the Health and Social Care Act 2012. The latest reform has to be understood, however, in the context of past market reforms in primary care, that is, services provided by GPs, dentists, pharmacists and optometrists that usually form the first point of contact for patients. Specifically, the changing role and type of GPs will be examined.

Attempts to transfer more decision-making power about service provision to GPs have been made repeatedly through past primary care reforms, yet the outcomes were ambivalent. The experience with GP fundholding in the 1990s has shown that not all GPs were enthusiastic about gaining greater managerial influence (Surender and Fitzpatrick, 1999) and efforts to support ‘entrepreneurial’ GPs to set up as social enterprises since the mid-2000s in fact strengthened large-scale commercial providers of health care (Heins et al, 2009). Given that the transfer of commissioning decisions is taking place in a time of heightened budget pressures, it is likely that GPs will take up the opportunity to outsource their new decision-making powers to the private sector.

First, the rationale behind a general trend towards marketisation of the UK NHS is briefly reviewed and the concerns related to such trends are highlighted.