As the consultation on the White Paper Liberating the NHS draws to a close, health secretary Andrew Lansley appears unflinching in his belief that GPs will embrace his commissioning plans.
Speaking to GP at the DoH's Whitehall headquarters, the health secretary is relaxed but at times defensive.
Mr Lansley explains clearly why he believes GP-led commissioning will out-perform the PCT-led model. GPs make the decisions that affect spending, and are therefore better placed to control budgets than PCTs. Exactly how this will work in practice can seem a little hazy, perhaps in part because of Mr Lansley's insistence that how services are shaped must be decided locally.
Professional concerns
But so confident is he that GP commissioners will do better than PCTs, he has a tendency to bat away some of the profession's biggest concerns.
Asked how he will deal with failing consortia, he says: 'That's a bit negative isn't it? You're GP newspaper and you think GPs are going to fail?'
When pushed, the health secretary says he will allow consortia to manage themselves to a degree, with performance management from the NHS Commissioning Board as 'light touch' as possible.
He admits that 'where there are clear risks you may have more intensive forms of monitoring', but adds that details of the NHS Commissioning Board's powers to intervene will be set out later this year.
Mr Lansley accepts the reshaped NHS won't be perfect. 'There will be failure. One of the responsibilities of the consortia will be to manage the responsibilities of their constituent practices and if necessary, step in,' he says.
Where a whole consortium is failing, the NHS Commissioning Board will either 'take over commissioning in the area, reappoint interim management or will instruct a neighbouring consortium to take over'.
He also seeks to reassure those who fear private sector takeovers where GPs fail. He is clear that, as statutory bodies, consortia must have an accountable officer from the 'general practice community' - and responsibility for services will remain with local GPs.
'It is important GPs have access to commissioning support (from third parties) but the idea is not to supplant their responsibility,' he says. 'The practices themselves should constitute the consortia and from among themselves identify who is the accountable officer.'
The health secretary trusts GPs. More so than the previous government, which became obsessed with telling GPs how to do their job, he says. He promises greater freedom from DoH or PCT 'interference' not only in commissioning, but in GPs' core contracts.
'The government stepping in and saying you have to be open in the morning and the evening while it doesn't say you can shut for lunch or for training... this is madness,' he says of the extended hours deal.
'If we structure the QOF genuinely on quality and outcomes we should spend far less time interfering.'
'Clarity and simplicity'
Mr Lansley wants to head towards a single GP contract, for 'clarity and simplicity'. In response to concerns that the NHS Commissioning Board will struggle to operate more than 8,000 primary care contracts, he says it will 'not behave like PCTs did'.
The board will disregard 'a lot of the thinking in the way PCTs have managed primary care contracts'. He added: 'We expect greater freedom for GPs.'
Although GPs will welcome talk of greater freedom, they are worried about having to ration NHS services as commissioners. But Mr Lansley makes no apology for putting the profession in this position. 'I don't think GPs think the best solution for the care of their patients is for other people to be responsible for them,' he says.
'Ninety-one per cent of people trust their GP. That is the best basis to make those decisions - and yes, that means tough decisions.'
But won't the 'postcode lottery' of treatments worsen as GPs are handed the rationing decisions that were previously made by NICE?
'People will set different priorities because they will have different patients - but what we will escape from is what patients most resent - when the GP says 'this is the treatment that should be provided' and someone with no clinical knowledge in the PCT says "No, you can't do that".'
The challenging timetable for reform has been set for a reason, Mr Lansley says.
'We seem at the moment to have areas that want to start straight away. Others want to wait and see and want answers to all the questions before they put their foot in the water. For that group, no timetable would give sufficient time - so we have to maintain a fast pace.'
For all Mr Lansley's confidence, his final remarks are telling: 'I do hope there will be enough places where it is working across the country to give confidence to others.'
With GPs' enthusiasm for the policy in the balance, Labour and the unions lining up to block it and parliamentary scrutiny to come, the health secretary still has plenty of hoping to do.
