Why GPs should not be commissioners


A version of this blog post has been published in the British Medical Journal and can be accessed at:


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4 Responses to Why GPs should not be commissioners

  • Salem says:

    “Autonomy, choice and empowerment are all well and good but they are not relevant in the context of decisions about scarce resources, this is a context where justice is the relevant ethical consideration.”

    But justice is not an abstract notion divorced from autonomy and choice. Most decisions about scarce resources are in the context of a market economy, where the aggregation of autonomous choices is what determines both price and allocation of resources. The issue with the NHS is that consumption of medical care has been divorced from payment. You glibly state that “On the current system resource allocation decisions are … [made] through a well-developed, accountable system” but to whom is the system accountable? The patient? The taxpayer? As you are surely aware over the past 12 years NHS spending has tripled, while clinical outcomes have hardly improved. This does not speak well for the resource allocation decisions.

    Ultimately, it is up to you to demonstrate the counter-intuitive notion that a bureaucratic managerial system will make decisions more wisely than the GPs and patients. Yes, it is possible that democratisation will mean “fat people and foreigners” receive less resources than at present. Well, if that is what the people want, wouldn’t that be a good thing? Moreover, the more democratically accountable we make resource allocation, the more of a downward pressure we put on costs, as opposed to an internal NHS system that acts as an eternally upward ratchet on costs.

  • Ketan Shah says:

    “Crucially, these decisions are removed from the individual doctor/patient context…”

    I’m not clear that you have argued why this removal is “crucial”. To the extent that large scale resource decisions represent aggregations of small scale clinical decisions (and we’d have to except large scale activities such as building hospitals and NHS management to make this jump), surely the moral arguments are the same?

    So if paying for Mrs Smith’s hip operation impacts on the statin Mr Jones gets, is there any moral reason for the GP not to be aware of this? Indeed, if the consultation is a meeting of equals, is there any reason not to discuss this fact with her?

    As a hospital specialist I’d be keen to stress that the same issues exist in hospital consultations, wards and A+E departments as in GP surgeries. While the services are not commissioned here, the resources, and the games to increase resources on this side of the commissioning fence, are all important.

  • Mark Sheehan says:

    Hi Salem,

    Thanks for your post. A couple of things: I understand the principle of justice and the principle of respect for autonomy to be different ethical principles (you might think that one matters more than the other or that one doesn’t matter but they are distinct). The way to see this is to grant your suggestion that the decisions about scarce resources are made in the context of the market economy and hence that these are the product of aggregated autonomous choice – we can clearly ask whether this situation is just.

    On the accountability of the current system: I do realise that there is variation in the processes of decision-making across the country, but where these systems are functioning well, they are accountable – to the people (i.e. taxpayers and patients). These decision-making systems might not be very high profile but the minutes of meetings and the decisions made are normally available on the internet.

    On the spending increase in the NHS: I think we need a bit more evidence about the cause of the spending increase. That is, it is far from clear that the decision-making system itself has been at fault or whether it has been public and political subversion of the process that is responsible – consider here the Herceptin decision-making. North Stoke PCT decided that Herceptin was not cost-effective and that it could not afford to be funded, but the minister, after the public lobbying, ‘suggested’ that the PCT should find the money.

    On the onus of proof: I understood the point of my argument as being to show that GPs ought not to make these decisions. I’m not sure whether they’re wiser but according to my arguments they’re morally preferable. Incidentally, it’s not the managers that make the decisions – the managers support the panel of GPs, public health doctors, clinicians and lay members in the making of priority decisions.

    Finally, I agree with the importance of democratic accountability but I think that we’re closer to it with the current system than we will be with GP commissioners.


  • Mark Sheehan says:

    Hi Ketan,

    Thanks for your post. I think this is a really nice point. In the post, I suggested that there were particular pieces of personal information that the GP knew about Mr Jones and which were conveyed (in line with the justification of confidentiality) in the understanding that they would be for the purpose of benefitting Mr Jones. As it turns out this information is used to Mr Jones’ detriment. The ‘crucially’ refers to this difference between the contexts.

    Your main point though (as I understand it) is that surely this personal information is morally relevant to the decision and so should be included. I think that’s right but, as you point out, only in the context of a meeting of equals. This takes us back to the role of the GP and the way in which expectations about preserving confidentiality arise in the context of a visit. If we changed the role of (and hence the expectations on) the GP to be one that included an awareness that GPs were explicitly rationing between individual patients, then we would be closer to a meeting of equals – except that one party would be sick and the other would have the possible treatment.
    More importantly, it’s hard to see, in this state of affairs, that we would actually need GPs (or doctors more generally) as we currently understand them. Instead the medical profession would be a collection of diagnosticians and technicians. My talk about the role of the GP was intended to suggest that this would be an unfortunate development.

    In the hospital, I think the same thing applies. Indeed one of the ways in which guidelines and admissions criteria for Intensive Care Units function is precisely to distance the clinicians from the difficult resource allocation decisions between two individual patients.


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