In all the discussion about why we should be opposed to Andrew Lansley’s NHS reforms, one of the points which seems to pop up most frequently (in this excellent article here, for example) is the potential conflict of interest that could exist when healthcare commissioning powers (and budgets) are handed to GPs.
The argument is simple: under the reforms, GPs are to be handed control of large budgets and the power to decide both what healthcare to buy to meet their patients’ needs and the generosity of their own salary and benefits packages. As such, people will no longer be able to absolutely trust that their GPs are making treatment decisions with patients’ best interests at heart, since they might be reluctant to pay for expensive treatments if that meant their own remuneration would suffer as a result. But how convincing is this? I’m not saying the reforms aren’t misguided in general, but on this one point, I’m not so sure. And by that I do really mean I’m not sure – anyone who has something useful to contribute on this to try and convince me one way or the other is more than welcome to do so.
There are two possible ways this conflict of interest might be a cause for concern:
- GPs really will start spending less on patient care and providing worse treatment at the expense of lining their own pockets.
- Patients will worry about the possibility that their GPs will do (1), and as such will no longer have the faith they do at the moment in the advice their GP provides.
For the most part, (2) seems to worry most commentators more than (1). This focus might be political – many GPs are themselves opposed to a lot of the NHS reforms, so it’s clearly counter-productive to suggest that they’re motivated by greed if you want to keep them onside. Equally, however, people might be worrying more about (2) simply because they don’t think (1) is likely to be that widespread – it seems reasonable to suppose that having chosen medicine (and specifically general practice) as a career, the vast majority of GPs care quite a lot about patient care. Besides which, if (1) ever actually occurred it would be a fairly clear violation of the Hippocratic Oath (“…I will apply, for the benefit of the sick, all measures [that] are required …”).
So, if (1) is unlikely to happen much anyway, does that in turn make (2) unlikely? I don’t think so. Oath or no oath, doctors are human and therefore fallible and imperfect, so it’s perfectly plausible that a small minority might end up doing (1). And, crucially, all it would take for (2) to occur is one case of a doctor providing inadequate care and enriching themselves to garner enough media coverage to turn it into a full-blown scandal.
What bothers me about the conflict of interest claim is rather different: put simply, if conflicts of interests really are a concern, how far would GP commissioning really make things worse compared to the status quo? As things stand GPs are paid pretty generously compared both to their counterparts in other OECD countries and to their specialist colleagues in the UK. This is the result of pay negotiations between GPs and the government, so in effect GPs had an indirect say in how much of the health budget should be set aside for their pay – and since the result of the last round of negotiations in 2004 was a big funding increase, it seems likely the GPs’ say is quite a big one. Did some other government spending commitment take a hit as a result of more money being allocated to GPs’ pay? Unless the government taxed or borrowed more to cover the shortfall, it must have done.
So what’s the substantive difference between this and what would happen under GP commissioning? Under the present system, GPs can already negotiate for their pay from a strong position, and do so in the knowledge that any extra revenue they get as a result is money that’ll come out of government spending elsewhere – most likely elsewhere in the health sector – so there’s still plenty of potential for spending on patient care to suffer at the expense of GPs’ wages. If we should worry about whether to trust GPs when they get commissioning powers, should we really worry about it any less now?
None of this is to say that we shouldn’t oppose the NHS reforms – there are any number of reasons why we should, set out very well by Richard at NHS Vault and any number of others. Nor am I saying that GPs won’t pay themselves too much at the expense of other health spending if the proposed changes go through. But if this is the case, then there’s plenty of potential for that to happen already. In this one respect at least, I’m not convinced Lansley’s reforms would be significantly worse than the present system.