GPs are set to oust PCTs as the NHS' key commissioners and budget-holders in England, if the Conservative Party has its way.
A policy document cheekily dubbed a 'White Paper' makes the 10 core principles of the NHS Plan statutory; but even more impertinently challenges the government to collaborate in bringing forward legislation to make this possible in the next parliamentary session.
The Conservatives' focus is a promise to return clinicians to the heart of the NHS.
'We will promise to transform a demoralised service where productivity and performance has stalled into one that re-engages professionals and re-empowers patients,' shadow health secretary Andrew Lansley pledged in London last week.
GPs will be glad to hear that he does not think they are overpaid.
'GPs are paid as very senior public servants and as public service professionals they know that they are not only required to exercise their professional judgement in relation to the patient in front of them but they are also required to take responsibility for the use of resources,' said Mr Lansley.
Under the Conservatives' proposals in a paper called 'NHS Autonomy and Accountability', NICE would be a statutory body, but its decisions would be advisory. Deciding which treatments to prescribe would be in the hands of clinicians.
Consortia of GPs would be in charge of commissioning primary care. PCTs, while remaining commissioning bodies, would be left to allocate budgets and define Health Improvement Plans (HIMPs), working under a new statutory requirement to consult with their local authority.
Practice-based commissioning is close to the Tories' heart.
'The centrepiece of the commissioning framework is the clinician commissioner working in primary care,' the paper says.
But the party believes it needs strengthening, GPs need to hold real budgets, they need the power to hold contracts with providers and to adapt them, and they need the power to reinvest savings into patient care.
The Tories accept that clinicians may find themselves at the centre of tensions between commissioning and national standards.
'The commissioning clinician will have the balancing responsibility and will remain accountable for his or her decision.'
Three income streams will flow into GP commissioners' pockets: first, payment for a 'simplified' quality framework that 'will incorporate a much greater emphasis on actual outcomes for patients, including patient self-reported outcomes'.
Practice income will also revert to a simple capitation-based payment.
The third element will comprise fees - for services such as out-of-hours care and opening at weekends.
The Conservatives believe GPs want to take on more commissioning and they want to commission out-of-hours care.
'GPs would be perfectly willing to take a greater responsibility for commissioning out-of-hours care in which they themselves would to varying degrees be willing to participate,' Mr Lansley said.
GPs would receive performance-related pay, a reward for adding value to patient care. This, Mr Lansley said, will correct the bias inherent in the quality framework that makes it easier to reach payment cut-off levels in affluent areas than in poor ones.
'We'll be paying GPs according to the improvement in their performance,' he said.
Central targets will be abolished, replaced by outcomes, 'allied to greater use of patient satisfaction surveys and greater use of patient reported outcomes'.
But Niall Dickson, chief executive of the health policy think-tank the King's Fund, said that targets were a big factor in driving down waiting lists.
On the proposals for performance-related pay, GPC chairman Dr Hamish Meldrum said: 'We would have to be convinced of the need to extend the process of performance-related pay any further and be assured it was fair and based on sound evidence of benefit to patients.'
The White Paper also promises to free the NHS from political pressures by setting up an NHS board 'to ensure that political interference does not result in the distortion of clinical priorities and the denial of autonomy to frontline NHS clinicians'.
Board members would include clinical, financial and commissioning interests and be appointed by the health secretary. The board would be accountable to parliament. But Mr Dickson said there was a risk of moving from one centralised system to another that was no longer accountable to ministers.
Under the Tories' plans, the patient voice would be strengthened by continuing Labour's commitment to the new Local Involvement Networks (LINKs) set to supplant patients' forums. Healthwatch will act as the national LINKs umbrella and as an independent advisory body on complaints.
THE TORY NHS VISION
Conservative 'White Paper' launched last week in London
- Independent NHS board to oversee commissioning
- Strengthen practice-based commissioning with real budgets and greater contractual powers
- No NHS re-organisation
- Emphasis on outcomes not targets
- GPs to be paid for out-of- hours care