The GP: Interview with Dr David Wrigley

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How do you think the [government's healthcare] reforms will affect your relationship with your patients on a day to day basis?

I think if the reforms came in, the concern [would be] that patients will think in a consultation, “hang on, is that doctor making that decision because of my illness or because of the funds he's got in the pot in the local health economy?” Because without a doubt – and I agree we need to look at the cost of the procedures, at how much drug costs are - with these reforms patients will be thinking, “hang on”. And there's this talk of payments to doctors if they save money in their consortium. Patients are going to think, “hang on, is he giving me that cheaper drug so he can buy himself a new car or pocket some money?”

Can you explain how it works now when patients come to see you and you commission services for them, and how you think it will work after the reforms?

At the moment Primary Care Trusts [PCTs] are still the statutory body and they're ultimately responsible for the healthcare budget. They have a set amount of money and they will commission services in the local health economy; they'll have a contract in a local hospital to provide A&E services, outpatient services, operations. They'll contract with GPs to provide primary care services and offer many others like long term care in nursing homes. That all has to fit into the budget they've got. So it's a tricky thing to do but you manage it. That budget, in effect, is going to be handed over to the GP commissioning consortia and those decisions will then have to be made by the GP groups. There's talk of the make-up of those boards being changed but we're not sure how that will work yet.

This [actually] started many years ago. It's quite a large practice that I'm in and we're also in a commissioning group in that area. All the practices are involved in the new commissioning arrangement. It's a very cohesive group and we have been doing commissioning for five years. From the outset it was difficult because you change your mind-set and the managers in the PCTs are unclear about the way forward. But as things evolve we've got a good relationship and we became more involved in decisions. GPs are seeing patients day in day out. They know what patients are experiencing in the hospital, they can see sometimes things happen that aren't a great experience for the patient. Sometimes they can see wasteful things happening. That's why I think GPs are in a good place to try and redesign the local health economy but working very closely with consultants and other health professionals.

And that's what the reforms are described as encouraging.

I'm someone who says the commissioning, as it is now, is working well. But what I don't want to see is the opening up of healthcare to the private healthcare sector. In my area in two years time our consortium will fully take over and the PCT will cease to exist. As of this month, although we do have decisions to make, choices to make, the ultimate responsibility is still with the PCT. If we had no health bill at the moment and we carried on as we are with the current situation - that the PCT disappeared in two years time - then I see that as possibly a good way forward for the NHS without the need for any of these laws or health bills on the statute books.

The health bill is there merely, I feel, to change the way the NHS works. The ideology of the government is to introduce the private sector into healthcare. The private sector will still – this is the clever part – have the NHS banner on it and it'll be badged as the NHS, but they'll be there to make a profit. Private companies want to make profits and please their shareholders. Now I fully accept doctors work for the NHS, they take home salaries, but that's very different to a large corporate company wishing to increase their share price and please the boardroom.

Nick Clegg said, talking about worries about competition and private companies coming in, “we say yes to a family doctor choosing a nurse's co-op to visit you in your home, we say no to a US-style healthcare system where they check your credit card before they check your pulse.”

That's all very well but the wording of the bill as it stands now doesn't do that. It will introduce competition, it will introduce the market and then it will introduce insurance based healthcare systems like you see in many countries. I've said all along I don't see that we need this legislation. Commissioning is happening now, successful in some areas. Cumbria's successful, my area's progressing well and we've got no legislation. There's nothing on the statute books. The commissioning is working well, we're developing good relationships and changing the NHS. I don't know any doctor who disagrees with the fact that the NHS needs to evolve, change. Money is tight so maybe we need to make decisions about how we use money, but I see no reason to do these massive reforms. The NHS, many people have said, and there are many surveys, has an all time high satisfaction rate. Waiting lists have plummeted, the Commonwealth fund I think gave a report that the NHS was the second best healthcare system in the world [see here] And there's no political mandate either. None of them mentioned this in the election. It wasn't even in the coalition manifesto and yet we see these massive upheavals in the NHS, when the politicians said there's going to be no top-down reform of the NHS.

Say I'm a patient, I come to see you, as it is now, at the moment, before the bill goes through, and you diagnose me with something. What's the list [of providers] that you can choose from? How much choice do you get in where you send me at the moment?

Theoretically you can choose to go to any hospital in England.

That's now?

Yes, that's patient choice, but 99 out of 100 of my patients that I refer want to go to their local hospital. They want a decent, local, good quality healthcare service.

So how will that change, do you think, after the bill goes through?

Politicians are denying that private companies will be able to cherry-pick, say, the routine, easier operations that are profitable, but the worry is that could occur and then could destabilise local hospitals as services start getting taken away from them. I think if you speak to hospital managers, they'll say that the routine, straightforward procedures subsidise other parts, other complex operations. People who need to be on intensive care [for example], which is very costly. So if those ones are taken away, it destabilises the hospital.

So can't you just send people to the NHS provider?

It depends again – it's unclear - but Monitor's [which will become the economic regulator for healthcare nationally if the bill goes through] role may dictate that you send the patient to the cheapest provider. It may well be good quality – I'm not denying that it will be of a certain quality - but if hospital 'a' offers a procedure at £900 and private provider 'b' offers it at £800, Monitor may say, “hang on, you've got to choose this one because it's cheaper and it's better value”. And the politicians have, in a way, been trying to deny that and roll back from that but it's still unclear.

Because they've said that price competition won't go ahead.

They did but it's a bit unclear about the whole role of Monitor. The main worry is around that competition aspect.

Do you think that you're going to have a list of every possible provider in the country that does hip operations and you and your patient can choose from that, or is your consortium going to say, “this is the list that we choose from?”

Well, it's a good question and I think again there are so many imponderables. There could well be a big picking list of, say, hip replacements, all over the country now. Again, they may say it's a fixed price, or they may say it could vary but most patients do want to go to their local unit if it's good quality and they're happy with it. It's a little unclear about the prices and how, if someone else is offering it at a cheaper price, and the patient wants to go [to their local unit], that may happen.

But that's good no? It's cheaper for the NHS, it's better quality for the patient, and other parts of the NHS that need to be subsidised can be subsidised more because there's more money that has been saved.

It depends how it happens really. If you're the provider, again, cherry-picking these operations and taking them away from the local district general, that does threaten other services within that hospital. You need an A&E department and you need a surgical department to see the people who are in A&E. So if you start losing bits of hospitals, suddenly the hospital becomes not viable to carry on doing the services it does already.

One of the ways the reforms have been justified has been by saying there are too many managers in the NHS, too much bureaucracy. We need to cut out the bureaucracy, we need to put clinicians and medical practitioners in the centre of the reforms. That's where you come in I suppose.

It's happening already. Managers are leaving PCTs now, management structures are being slimmed down. In my area we're working closely with some key managers who are still working in the PCTs, but many of them have moved on.

Because of the reforms?

I think so. They've either been offered redundancies or they can see that, hang on, this PCT's not going to exist in two years, I'm going to find another job that's a bit more stable and secure. And who can blame someone doing that if they get a job offer?

But, you know, I think any doctor you speak to would probably say that there has been too much top down bureaucracy, too much micro-management. Doctors have been told to tick boxes and meet targets and it's all been managed by people who have been told to do this by the Department of Health, so I think there is a need to reduce the bureaucracy. Patients I speak to always agree with that as well. That's not denying you do need some good management. You need the structures there, you need finance directors. GPs aren't accountants or commissioning experts. So you need these people to support you and help you make the right decisions.

Do you think you'll have time to do all the commissioning?

It's a good question. In my area there are many GPs but there are only four GPs that have taken the commissioning role. That's only for a day a week as well, so there's still four days a week to undertake clinical work. We're not talking every GP needs to get involved with this and I think that's a little bit of a false argument: most GPs will carry on doing their day jobs, seeing their patients. That won't alter. It just needs a few GPs to take on the leadership role within an area, to do the work and meetings that are required to set this process going.

So how are the GPs who are going to take on the leadership role chosen?

In my area we've had a proper election with all the GPs, including salaried doctors, out of hours doctors, locums. There was an open election process. You could stand and there was an election after. I think that's the way every part of the country should do it.

Do they have to do it like that?

They don't have to, no. We saw it as a good way of getting the buy-in from local GPs, so they felt ownership of the process. The GPs there now, in that role, they've been chosen by them, not like in the past when PCTs, or others, have chosen GPs and placed them on committees and boards. That's led to disengagement by colleagues. So I think the election process and the way the board's set up is actually quite positive.

There are some real issues around GPs on commissioning boards making decisions when they are perhaps involved with provider companies. The conflict of interest there could be quite significant. It's very important that's sorted out, that GPs are open and declare it, because it could lead to very big problems with the doctor-patient relationship. Again, the patient thinks, “is he sending me to that provider because he gets a cut of the money being used?” So I think it's an issue that needs clear guidance. But there's been no real guidance, I don't think, from the Department of Health on this. I think the BMA's trying to give some guidance but it's a very live issue.

And should it be just GPs on the commissioning consortia? Should patients be represented for example?

I've no strong feelings either way. I know in my area we're working closely with consultants, public health colleagues, we’re speaking to nurses, the voluntary sector and charities. We're engaging in a way that we've never engaged before with colleagues. So in a way, who sits on the board, I don't think that's terribly important.

Is it in the last year that you've been more engaged?

Yes. We've met with forty consultants and found out where the issues were, what their frustrations were and how could we improve the services in the hospital. That never would have happened under the previous regime. The dialogue there is far, far better. That's why I'm in a way positive about the commissioning, but I'm very much against the whole health bill and where that will lead the NHS. If you read the bill, which is a very complex, legal document – it's like wading trough treacle, the bill is there to allow any willing, sorry, it's every qualified provider now, to offer their services. That's the whole ethos of the bill, allowing them to tender and provide services for the NHS.

So would you have said commissioning but not competition?

Yes. Even commissioning but no health bill. We're doing it now, we've got the structures in place, and we’re talking to colleagues and consultants in a way we've never done before, improving the NHS, hopefully.

But the commissioning consortia have only come because you've been preparing for [the bill]?

It's been set in train for four or five years.

Under Labour?

Parts of the country are at different stages. Some have hardly done anything because PCTs either haven't brought it about or the local GPs didn't want to do it. Obviously these reforms say you must do it, but I think we could have got around that by just changing the way the structure works and by reducing the bureaucracy as we've discussed already.

What do you think people should do about the health bill?

It's important we get the message out there to patients and the public about what this health bill means. We've seen it with the forests that the government can change their minds and alter policies, and I hope that happens with the health bill. It's up in the air at the moment. The government are on the back foot, they're already panicking I think. What we saw with the health secretary and prime minister standing up and saying, “we're stopping, we're pausing”, that's not a decisive government who knows its policies. That's a government that hasn't thought through its health reforms. To me that says we need to drop this bill and stop these changes that could damage the NHS for a generation.
See also:

The community nurse
March 24, 2011

The community nurse
March 24, 2011

The radiologist
March 24, 2011