Consider a patient of mine - call him Ralph. Ralph is in his late sixties, and for the past couple of years his life has been blighted by pain from an arthritic hip. He was never the slimmest of specimens, and the resultant limitation on exercise has compounded his weight problem. The extra load is causing more strain, and yet more symptoms. We have exhausted our options in painkillers. He limps in to see me, lowering himself stiffly into the chair by the side of my desk. Something needs to be done, he tells me. "I can't go on like this."
A physiotherapist could help Ralph, but the local department is overrun - all he'll get after months of waiting is a leaflet. Losing weight would improve his pain, too, but he has tried and failed with DIY attempts in the past, and the NHS is only beginning to wake up to the need for comprehensive weight-reduction services. Hip replacement is an attractive, if expensive, option: it's a good treatment for pain, and thanks to waiting time targets he is likely to be sorted within 18 weeks. Except overweight people do less well after operations, so, even if the surgeon decides that Ralph merits surgery, he may decline to proceed until he has shed a couple of stone. Oh, and yes, Ralph would also recover far better if a physiotherapist were to help him improve the strength in his hip muscles before he goes under the knife.
This hotchpotch of options in England is one of the things that Andrew Lansley hopes to improve with the Health and Social Care Bill before parliament. A lack of some services, unwieldy waits for others, departments working in isolation with no idea how they affect each other . . . all this comes about through piecemeal commissioning. Physiotherapy? Check. Weight loss programme? Good idea. Orthopaedic surgery? Sure, we need some of that. Get them working in concert to help Ralph? Well, that's a bit more tricky.
Central to Lansley's plans is the idea that doctors could do it better. At present, commissioning - the design and purchase of NHS services - is undertaken by non-clinical staff in your local primary care trust (PCT). In April 2013, PCTs will be abolished and their functions will be taken over by clinical commissioning groups (CCGs) comprised largely of GPs. Give us doctors control of the budget, Lansley believes, and we will make sure that the right services are available at the appropriate time to help Ralph. The idea is so novel that new terms have emerged to describe it. In future, patients will enter a "pathway" of "seamless" care, at the end of which they will emerge smiling and free from pain at last.
Bring it on, I hear you cry. There are, however, a few thorny matters to sort out. First and foremost is inexperience. The length of time devoted to commissioning during medical training is somewhere around zilch. Doctors may know what services our patients need, but it will require a whole new skills set for negotiating contracts with powerful providers such as hospitals. In my corner of south-west England, doctors and managers from every practice on the patch established a fledgling CCG over a year ago. This was months even before the bill was published, when all we had to go on was hints emanating from the Department of Health. At the time, the British Medical Association was advising doctors to hold fire; time enough to get organised once it became clear what we were being asked to do. But upheavals in the health service occur cyclically, on average every ten years. Experienced GPs have lived through several in the course of their career and are familiar with the desirability of being in the vanguard, to say nothing of the perils - for them and their patients - of being left behind.
Lansley's April 2013 deadline was always going to be ferociously tight. Few believed there was any option but to get on with it. And get on with it we have, at least on our patch. At the heart of our CCG is "GP Forum Plus". One afternoon a month, all 27 practices shut up shop, leaving urgent care needs of their patients in the hands of the local out-of-hours service. GPs and practice managers jump in their cars and scurry off to confer. The venue changes every month - not through clandestine considerations, but more to do with spreading the commuting burden in a semi-rural locality covering 220 square miles.
The "plus" in GP Forum Plus is education. Every month, the forum invites consultants from a different specialty to present ideas for ways of working. We have already established pathways for patients with heart failure, heart rhythm disturbances and several neurological conditions. The care of patients at the end of life has also been the subject of fresh thinking. A unifying theme is more care closer to home, with less activity in hospitals - better for patients, and more cost-effective.
While we have been gaining experience in pathway design and commissioning, the same is not true countrywide. In many areas, leadership is weak, and jobbing GPs are weary and resigned, casting envious glances towards Scotland, Wales and Northern Ireland, where Lansley's writ does not run. This picture explains the announcement by the government of a relaxation in the mandatory 2013 deadline for GPs' groups to assume commissioning responsibility. It is a U-turn entirely of the Conservatives' making. Their manifesto pledge of "no more top-down reorganisations of the National Health Service" stands as one of the more glaring examples of political chicanery of recent times, and it has provoked widespread cynicism and disaffection.
There is a great deal of apprehension, too. Lansley's reforms coincide with the requirement for the NHS to trim £20bn off its expenditure over the next four years. In our area, that translates into savings of roughly £10m year on year, a daunting prospect. Those still at the helm of the PCT are charged with delivering this for the next 18 months, but the time is fast approaching when we will have to take over. Failure to live within our budget will lead to an uncertain future for our clinical commissioning group. Though most of us are competent at running small businesses, the scale and complexity of a multimillion-pound organisation leaves us feeling more than a little deficient in the MBA department.
Another difficulty with Lansley's new-look NHS is that the model was based around patients just like Ralph - people with common, relatively straightforward conditions with clearly delineated treatments. This has been true of every reform since Margaret Thatcher and Kenneth Clarke introduced the "internal market" in the late 1980s. Attempts to commodify health care are inevitably based on beans that are amenable to being counted.
But consider for a moment another of my flock, a teenage girl we'll call Millie. Earlier in the year, after experiencing a few months of non-specific symptoms, she was diagnosed with a form of cancer so rare that it afflicts just a handful of children in the whole of the UK each year. Her treatment to date has involved three different hospitals and more than a dozen specialists in chemotherapy, radiotherapy, surgery, radiology and histopathology, not to mention the network of nurses and counsellors supporting her, her family and her schoolfriends. Services for patients such as Millie can never be reduced to pathways, and their complex or highly specialised nature puts them beyond the remit of generalist commissioning.
These sorts of considerations were impressed on the government during the "pause" in the Health and Social Care Bill's progress in the spring. In response, the Department of Health has proposed a range of external bodies to advise and moderate CCGs. Yet these layers of bureaucracy leave the new decision-making structures in danger of becoming even more byzantine than those of the PCTs they will replace. The nimbleness, innovation and efficiency Lansley envisioned when first drafting his bill may never come to pass, foundering on the complexity and irreducibility of much health-care activity.
By far the biggest concern for doctors, however, is the environment in which we will be expected to undertake commissioning come 2013. What most doctors want is the opportunity to develop the NHS as a modern public service, responding efficiently to patients' needs through innovation and collaboration. The haemorrhaging of support for Lansley's reform proposals - from which they have yet to recover - began when it became clear that the coalition government had swallowed the same competition-über-alles line that the Department of Health has been pursuing since the era of Thatcher and Clarke (a brief pause in the early New Labour years excepted).
The original draft of the bill gave Monitor, the health-service watchdog, the task of enforcing competition. Even though this has since been softened - Monitor is to promote competition only where it is perceived to be in patients' best interests - suspicion remains strong that the department is an old dog not much disposed to new forms of magic.
As a commissioning group, we are wrestling with the follies that these competition policies have engendered. A couple of years ago, it obliged our primary care trust to enter into a block contract with an independent-sector treatment centre (ISTC). The ISTC is paid a fixed sum annually for a set volume of clinical activity, and there is no break clause in the contract. The facilities are pleasing and the waiting times short, but many patients (and GPs) prefer the trusted consultants at the district general hospital. Add to the mix that these same consultants' own private hospital has started to compete for NHS work, and referrals to the treatment centre have fallen well short of the levels specified in the contract.
The trust is now paying for many procedures twice - once to the treatment centre for the unused capacity, and again to the hospital that does the work. This is madness, when we're trying to save £10m a year, yet the commissioning group's response - that we GPs have to "persuade" more patients to agree to ISTC referral until the block contract comes to an end in a few years' time - was slapped down as anti-competitive and anti-choice.
Paying twice for certain procedures is bad enough, but the seepage of routine work away from conventional NHS hospitals threatens the very viability of some of their departments. My local orthopaedic consultants are decidely glum about the impact on their staffing and ability to train the next generation. Treatment centres and private hospitals won't help elderly patients with multiple conditions who require surgery - they are considered too high-risk (and therefore too expensive), and will only ever be treated by the old-style NHS. And what about the likes of Millie, relying on centres of excellence whose financial foundations rest on a bedrock of unglamorous, routine work that is fast being undermined?
Another consequence of the Department of Health's fetish for competition from private providers is the corrosive effect on the public-service ethos running through the NHS. Public service is the reason I became a doctor, and the principal reason I still relish the job. This will only be attenuated if the institution is fragmented into a collection of franchises, with the resulting loss of much of the goodwill that has sustained the NHS since its inception.
Ironically, the work of our commissioning group is an example of this goodwill. There is no payment for attending GP Forum Plus. Absence of funding meant that the board members - devoting between one and three days per week to commissioning - were not paid for the first nine months, their time subsidised by their practices. But, as the argument goes, we are where we are and there is no turning back. If the Tories have shamelessly abused the democratic process, the actions of many others serve as a rebuke and a powerful corrective.
Health-care unions, royal colleges, independent think tanks and professional associations have exerted enormous pressure for modification of the least palatable aspects of the bill. Internet-based citizens' groups such as 38 Degrees (of which I declare membership) have harnessed the disquiet of hundreds of thousands of members of the general public to lobby politicians and to fund independent legal advice to challenge ministers' bland assertions about the effects of the bill. It is heartening that several concessions have been won thus far.
I am encouraged when I look back over 25 years of cyclical upheaval. Despite all the attrition and government dogma, I still broadly recognise the national health service I joined all those years ago, and I am hopeful the NHS can survive the present turmoil and remain something of which we can be proud when this generation of politicians is long forgotten.
Phil Whitaker is a practising GP and an award-winning novelist.