Power shift as GPs are given NHS purse strings

A decisive shift in the power balance of the NHS takes place today as the bulk of the £53bn budget for 2002-3 is put into the hands of doctors and nurses on the front line.

A decisive shift in the power balance of the NHS takes place today as the bulk of the £53bn budget for 2002-3 is put into the hands of doctors and nurses on the front line.

More than 300 Primary Care Trusts – groups of between 50 and 100 GPs – will take responsibility for commissioning services for cancer, heart and other patients from local hospitals as well as moving some clinics and services into their surgeries.

The change represents a seismic shift in the culture of the NHS, converting general practice from a cottage industry to a corporate entity, and is aimed at making the NHS more responsive to local needs.

Ministers believe by putting GPs and nurses in the driving seat of the NHS they will deliver a service that is more humane, caring and convenient than the consultant-led, high-tech hospitals that dominated the medical landscape of the past century.

The PCTs are taking over many of the responsibilities of the 99 health authorities in England, which formally ceased to exist yesterday, and will be responsible for 50 per cent of NHS spending immediately rising to 75 per cent by 2004. Overall planning of the service will be taken over by 28 strategic health authorities which will have a largely public health function.

Alan Milburn, the health secretary, has been criticised for ceding too much power to Whitehall and running the NHS from the centre. But in a briefing for journalists to mark the change last week, he said today's change amounted to a huge process of devolution from Whitehall.

"For the first time in the NHS's history, the resources, responsibility and power will not be held in Whitehall but in the front line services. It marks a watershed with a transition to a different sort of health service. GPs will be in charge of 75 per cent of the resources and where they are spent, recognising local communities have different needs. I think that is a set of profound changes."

He warned the success of the new system depended on the PCTs being able to use their bargaining power and shop around without being bullied by NHS trusts many times their size. "It is very important NHS trusts open their books so that PCTs can be sure they are getting value for money. In some areas, there is a good working relationship but in others that is not the case."

The changes were foreshadowed in a White Paper published in December 1997 that marked the end of GP fundholding and the internal market created by the former Tory government. Under the fundholding scheme, GPs were able to buy only routine surgery and other routine services for their patients and never controlled more than 15 to 20 per cent of the hospital budget.

The British Medical Association warned that many PCTs would start life saddled with debts left by the old health authorities, estimated at £1.6 bn nationwide. It criticised the speed that the changes had been pushed through and said there were doubts about the calibre of management in PCTs.

It also questioned whether it was practical for individual PCTs to negotiate with hospitals alone. Hamish Meldrum, vice-chairman of the BMA GPs committee said there had to be a trade-off between local control and duplication of effort.

He said: "In my own area of Hull there are two PCTs where there was one health authority. It is logical for them to get together to arrange services with the local hospitals rather than doing it separately."