Good evening.

You may have already seen the new instalment of Maynard Doctrine, in which the good Professor points to the pointlessness of NHS reorganisations. This piece may have been prompted in part by Professor Chris Ham’s musings for the BMJ that the White Paper reforms may not even be enacted as planned.

Interesting times.

The service is to reply upon GPs – whose earnings, although slowing in growth again for 2008-9, as ex-Dr Foster Intelligence shareholders the NHS Information Centre has shown.

The IC work finds that “in 2008/09, average income before tax for GPs holding a general medical services (GMS) contract (the type held by the majority of contractor GPs) was £99,200 (for the UK) compared to £51,500 in 1998/99 (for GB)” – not-bad healthcare inflation.

It “shows average income for contractor GPs also fell slightly in each country of the UK, with average income before tax at:
£109,600 in England (a decrease of 0.5 per cent since 2007/08)
£86,500 in Scotland (a decrease of 1.0 per cent since 2007/08)
£90,700 in Wales (a decrease of 2.9 per cent since 2007/08)
£89,700 in Northern Ireland (a decrease of 1.5 per cent since 2007/08)”
and also – wildly unsurprisingly, found that “average income for contractor GPs during 2008/09 was higher if they offered dispensing services (£121,500) than if they did not (£102,500)”.

Incentivising PMS
No, not pre-menstrual syndrome – the report also shows quite an interesting, though again ultimately unsurprising thing: “average income during 2008/09 was £116,300 for those holding a personal medical services (PMS) contract compared to £99,200 for those holding a general medical services (GMS) contract”.

It seems that paying ‘salarymen’ GPs to do specific things means that they will do them.

What will all this mean?
It will mean things for dragging GPs into enthusiasm for the new system.

Which the framework RCGP document indicated is going to be what is known in the vernacular as “a big ask”.

Lansley has been doing a range of roadshows to sell his project to the NHS, and GPs have been one of the target audiences. At one such meeting, he responded to various key concerns raised by attendees in the following (paraphrased and summarised) terms.

Bureaucracy – how bureaucratic will GP commissioning consortia be?
Liberatin’ Lansley understands that reducing the ‘returns for returns’ sake’ culture will be key to generating the enthusiasm and buy-in to allow the new structures to work.

Responsibility for premises, IT, performance procedures, performers list and appraisals?
LL in diplomatic mode pointed out that this will have to be negotiated with the BMA’s GP Committee. He expects the performers list, appraisals and performance procedures to be handled at the Independent Commissioning Board level – presumably to be done by regional offices.

He was not explicit about premises and IT, but seemed to indicate that his preference would be a capitation funding to practices.

Inherited debt
Significant debt would disincentivise engagement - GPs are concerned that they will inherit debt from PCTs or be tied into contracts for ISTCs, Darzi Centres or PFI.

No promises on PCT debt, but LL “is keen” that GPCCs start with a clean sheet. Unclear how this will be achieved. Darzi Centres and ISTC contracts will have to be honoured as NHS contracts, and “we will have to live with the consequences of these”.

More interesting on PFI – currently, PCTs repeatedly bail out failing trusts. GP commissioning consortia will not be expected to do so. Since all provider trusts will be FTs, Monitor will have an enhanced role in this area.

NHS pension
As all provider trusts become FTs (or fail) and may form social enterprises, does this mean that they move out of the NHS, en route to privatization and limiting access?

LL was expecting this one, and told the room that FTs are part of the NHS and would remain within the NHS and able to access NHS pensions - even if formed into a social enterprise.

GP commissioning consortia staff would be able to access NHS pensions.

A support agency (potentially made up of ex-PCT staff) for one or more GP commissioning consortia would be able to access NHS pensions unless they are LLPs or companies which are for-profit.