Myth five: GP commissioning will damage the doctor-patient relationship

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Part of The Health and Social Care Bill

Over the last quarter of a century, doctors have consistently been named the profession most trusted by the British public. The most recent (2009) MORI survey on this issue showed that 90 per cent of those questioned believed that doctors told the truth compared to 13 per cent for politicians.

The GP surveys conducted for the Department of Health also show that patients have high levels of satisfaction with their GP. In 2010, nine out of ten patients were satisfied with the care they received at their surgery and over half of patients were ‘very satisfied’ (54 per cent). Only four per cent of patients were dissatisfied with the care they received. This suggests that the current doctor-patient relationship is highly valued and that the public place a significant degree of trust in doctors as professionals. How might the changes proposed by the Health Bill threaten this?

What does the Health Bill propose?

The Health Bill proposes that all GPs will need to be a member of a GP commissioning consortium in order to have a registered list of patients. The consortia would hold £60 billion of taxpayer's money and commission the majority of hospital and community health services for patients. It is proposed that an element of GP pay would be linked to their consortium's commissioning performance.

What might be the dangers in these reforms?

If patients believe that GP decision-making is being influenced by personal financial gain this could erode their trust in GPs as professionals. The British Medical Association has raised concerns about this issue.

There are two key ways in which financial considerations and patients' clinical needs potentially come into opposition and could reduce patient trust.

The first is at the point of referral. In the future, patients may believe that a GP has decided not to refer them for specialist treatment not on clinical grounds but solely because they want to keep the consortium within budget (as the GP would gain financially from this). Evidence suggests that many patients seek referrals that they don't necessarily need clinically, putting GPs in a particularly difficult position.

Further threats come from the proposed changes to the role of the National Institute for Health and Clinical Excellence (NICE). While NICE will continue to undertake economic assessments of new drugs, it will no longer be compulsory for GPs or providers to abide by NICE guidance. It creates the possibility in a patient’s mind that GPs might make and support prescribing decisions on economic rather than clinical grounds, again undermining trust. Both sets of circumstances underline how important it will be for GP consortia to have strong governance and transparent decision-making processes.

What might be the benefits in these reforms?

On the other side of this argument is the experience of GPs who have already been actively engaged in commissioning, many of whom have worked very closely with patients in developing services and taking commissioning decisions.

For example, the GP commissioning group Principa follow the principle that not a single decision should be made without patients being involved from the outset. This principle has brought patients closer to GPs and strengthened rather than damaged the doctor-patient relationship. It is likely that GP consortia will be required to provide evidence of how they plan to engage patients in consortia work.

Is it a myth or a fact?

We're still undecided. While the proposals laid out in the Health Bill do have the potential to undermine the high level of trust that patients currently have in doctors, they could also drive a much closer and more equal relationship between GPs and their patients. This is one to watch over the next few months.


Kate Mandeville

Specialist Registrar in Public Health,
Comment date
22 May 2011
The evidence laid out here for the potential erosion of GP-patient trust under the reforms seems to far outweigh the one example of a closer relationship (in which I presume rationing decisions are still made by the PCT and NICE guidance is followed). So I would disagree that you have "busted" this myth.

Local GPs, well-known to their patients, will need to make local rationing decisions rather than nameless organisations such as NICE or SHAs/PCTs. It will be difficult for GPs to both ration and be patients' advocates.

Andrew Parry

Care Service Manager,
Voluntary sector
Comment date
31 May 2011
Agree with Kate. As a social worker I have found over the last 30+ years that my ability to advocate for the client has been steadily shackled by being forced to become the gate keeper to the (scarce) resources they require for independence. That is one of the reasons I left local authority employment to work in the charitable sector. Together with the team I manage I am now able to advocate freely for our clients and help them achieve the outcomes they want in their older age.

Jen Thorley

Web editor,
The King's Fund
Comment date
08 June 2011
Hi Kate and Andrew,

Thank you for your comments above. We would agree that this NHS myth is still to be decided, and have updated our final conclusion accordingly.

Mark Slade

Comment date
24 June 2011
History shows that - in any sector - the moment you give someone control of a budget, they feel a greater sense of responsibilty. Inexorably, this becomes reflected in the increasing amount they allot to themselves - so don't be surprised if you end up with a lot of very, very wealthy GPs!.

steve black

management consultant,
pa consulting
Comment date
30 June 2011
There are two key problems with this myth that arise because of the hidden assumptions made behind it.

Problem number one arises from the assumption that doctors have no financial incentives in the current NHS. But GPs stand to gain if they meet certain targets and are often paid for specific activity. Many hospital consultants gain from private practice where the doctor gains directly from payment via the patient (without apparently raising the conflict of interest) and where the amount they make depends on failures in the NHS creating a strong disincentive to improve poor NHS service. So it is hard to see why control of commissioning budgets would bring something new to the party.

Problem number two arises from thinking through the implications of the different decisions that might be made by a GP in control of a commissioning budget. The health system always has to judge how best to spend limited resources. It is not that obvious that GPs making rationing tradeoffs to achieve the best health outcomes for the patients in their population is a worse system than GPs ignoring the tradeoffs and hoping that some bureaucrat from DH will control the clinical thresholds. If being the patient advocate is about giving the patient what they want even if they don't need it and the NHS could spend the money better elsewhere, then how is that good for the NHS or the patient? GPs might find it convenient to blame NICE or DH for decisions, but unless our model of behaviour is GPs do what the patient wants regardless of clinical need, I don't see why the sort of decisions they might make should be compromised.

Sarah Lambert

Comment date
27 October 2011
I have a perspective as an end user. I had a persistent cough for three months or so and was repeatedly sent away by my GP with "It's probably an infection". However I knew there was something wrong as I had extreme fatigue, a pain in my legs, leg swelling and other unpleasant symptoms. I asked for a scan but was refused. Eventually I decided I had to take action and had a scan through my workplace health scheme and was diagnosed with bilateral pulmonary embolisms which can kill if untreated. I have the distinct impression that the practice does all it can to avoid referral, even though (as in my case) it is fully warranted by the clinical presentation. On another occasion I asked to be referred regarding HRT problems, but instead of a referral to a specialist, the GP told me she "had a friend she could ask about it".
The new role of GP consortia as financial gatekeepers will definitely compromise patient trust. I certainly no longer think my GP is my advocate in health matters, but rather someone I need to be wary of when receiving advice on my health.

E Brown

Comment date
27 March 2012
My recent GP experience gives me mixed feelings on this. Not only are GPs already reluctant to refer patients but they are reluctant to provide the most basic services you should expect - eg practise nurses in sufficient number to provide all the services that fall within their discipline. My current experience is that getting stitches taken out is one of the most difficult things to organise! I have passed from pillar to post and back because nobody wants the expense of providing this basic resource. I am currently in contact with local district nurses trying to get myself one of two appointments available to me! But of course I have to give up a days work to make myself available for this. Who says the NHS provides free services?! This little number has cost me £200 before my taxes are taken into account.