| By Sarah Montague
Today programme |
 Doctors will soon be prescribing the future of the NHS |
The government is planning the biggest ever shake-up in the history of the NHS in England. Will it work?
It wants GPs, rather than managers, to decide how and where to spend money for their patients and it will hand them £80bn of the NHS's £100bn budget.
The existing management layers will be scrapped and all this will happen within the next couple of years.
In the village of Ramsey in East Anglia, it is already happening. The Ramsay health centre is one of 10 surgeries in Huntingdonshire that make up the Hunts Health Consortium. It's one of the first GP groups to take over control of a real budget from their Primary Care Trust (PCT).
Paul Zollinger-Read, the head of the PCT in Cambridge, told me that a year ago he realised that if they carried on doing what they were doing then in three years time they would be £100m in debt.
He decided to work with local GPs because GPs write the prescriptions, make the referrals and are responsible for the majority of NHS expenditure.
"So put them in charge of making decisions and you have a much better model of healthcare," he told me.
His aim is to do himself and his colleagues out of a job because, he admitted, they were getting in the way and "frustrating the changes GPs could make".
The GP in charge of Hunts Health Consortium and who now controls the purse strings is Simon Brown.
The change, he told me, is revolutionary - it used to be difficult to get innovation which GPs see as obvious through, but now they can make "logical decisions from the patients perspective".
He and his colleagues will set guidelines for all 10 surgeries - what they think is the best and cheapest drug to prescribe for different conditions, what they consider the most effective way to treat conditions like diabetes and how they want to manage - and prevent - the particular health care problems that crop up in their area.
If a surgery wants to join their group they have to sign up to their way of doing things.
He says that it should mean fewer hospital admissions. Where patients are admitted, it should be for shorter periods.
Not all GPs are so keen. A short drive away, the surgery at Alconbury and Brampton has decided not to join the consortium yet.
The personal view Dr Duncan Outram, of one of the GPs there, is that it will damage the doctors' relationships with their patients.
At the moment, he argued, GPs are patients' advocates. But if consortia go ahead, then patients may start to worry about whether their GP is acting in their best interest or trying to balance a budget.
He also thinks patients will end up blaming their doctors for cuts that otherwise would have been seen as the responsibility of government.
It is a point Simon Brown is willing to acknowledge, but argues that at least, with GPs making the cuts, the decisions will be made "in rational ways".
Healthy debate
Hunts health consortium is ahead of the game. But over the next few months every single doctors' surgery in England is expected to make plans to join a consortium so the new system can be up and running by April 2013.
 Some fear NHS reform will open the door to a privatised health service |
It's reckoned there will be about 500 consortia. That should allow some GPs to take a back seat while other have a more active role running the finances.
The planned changes represent a huge shift of power to GPs.
Many support the thinking behind it, but there is concern about how it will work in practice.
A BBC survey of more than 800 doctors found that less than a quarter thought the changes would lead to a noticeable improvement for patients.
Chris Ham, chief executive of health think-tank the Kings Fund, has cautioned about the pace of change.
"It's quite risky to move from the current system to the new system at this speed and pace," he told me.
Others have voiced concerns about whether GPs have the necessary skills.
Paul Jenkins, chief executive of the mental health charity Rethink, has warned that people with mental illness don't necessarily get a particularly good deal now.
 |  In 10 years' time, shareholders in a large American-style healthcare company could have more influence over what services are provided by whom than a citizen  |
GPs themselves say that they are a lot less comfortable in treating mental illness than they are treating physical conditions.
He questions whether GPs have the skills, knowledge and interest in mental illness to make it a priority in the new world.
GPs may also decide that they'd rather spend their budgets on some conditions and not on others. Those decisions will vary across the country.
So, says Michael Dixon who chairs the NHS Alliance, you could be turned down for treatment at one surgery for something like IVF, when a neighbouring consortium is offering it to its patients because, for example, they have prioritised heart disease or cancer.
"That's the sort of flexible arrangement you can't have at the moment," he says.
"Ultimately what each consortium is doing is trying to make the best of the money it's got and therefore there will be winners and there will be losers.
 Layers of management are to be stripped from health care provision |
"But the main thing is that the clinicians and the local population feel corporate responsibility for what they decide."
And that is the aim of the reorganisation - to put the patient, with their GP, in the driving seat. It's a far cry from the way the NHS has worked over the years.
Since it was launched 62 years ago, such have been the demands on the service that it has turned into one of the biggest employers in the world.
As patients have wanted, and needed, more, the number of front-line staff has grown and so has the number of managers.
The government says the changes will cut management costs by 45% over four years.
Out goes all the existing architecture: Primary Care Trusts, Strategic Health Authorities and much of the power of the secretary of state.
It is, says Michael Dixon, "a fantastically brave and fantastically good option" and something that both GPs and their patient would embrace "very wholeheartedly".
Private concern
There are those, however, who fear it won't be long before big business muscles in.
"You can very quickly envisage a situation where the GPs aren't actually doing the commissioning themselves," warns Sarah Gorton of the union Unison.
"They're setting the criteria but they are handing over the commissioning - which isn't just about contract management, it's about identifying what the needs of the population are and then identifying who's going to be the potential provider for that and then awarding and managing the contract.
"There is a danger that we could see a creep to handing this over to the private sector.
"In 10 years' time, shareholders in a large American-style healthcare company could have more influence over what services are provided by whom than a citizen, a taxpayer, in a community in England."
Even Michael Dixon accepts that this is a threat. The way to ensure it doesn't happen, he says, is for GPs to embrace the change wholeheartedly, take ownership of it and make sure that they get their managers in to do the job.
It's not just the fear of privatisation in the commissioning of healthcare - some fear the increasing privatisation of those who provide health care services.
Chand Nagpaul, a GP with the British Medical Association, says one of their big concerns is that the government's ideological attachment to competition "permeates the NHS".
In particular he points to the setting up of a new body, Monitor, whose role is to promote competition within the NHS and intervene if it believes anti-competitive behaviour is taking place.
Dr Nagpaul asks if, as a GP, he decides to work with his local hospital to develop services, would that be anti-competitive and will Monitor tell his surgery to refer instead to private providers and the independent sector?
He warns such an arrangement would fragment care and undermine the efforts of GPs to serve their local communities with their local hospital.
Monitor will work alongside a new independent commissioning board whose job is to divide money up between the consortia and oversee what they do.
Much is unknown - not least exactly who is responsible for what and what happens when things go wrong.
Nigel Edwards, acting chief executive of the NHS Confederation, which represents most of the organisations that make up the health service, says that if GPs make decisions that they're not going to provide certain types of treatment, it's not clear who holds them to account.
He points out that if a hospital is not being successful in the market for orthopaedics and decides it wants to stop, under the new system it can do so unless it's an essential service.
"It can just exit the market in the way a shop might leave a town," he told me.
Health Secretary Andrew Lansley knows the NHS inside out after spending six and a half years shadowing his current role. This is his idea.
In opposition he talked about giving more power to GPs but the full scale of what he would propose was not clear.
One senior NHS figure said that this is the sort of change that takes 10 years in times of plenty and we are being asked to do it over 18 months while cutting budgets.
That David Cameron decided to sign off on it could be seen as a huge political gamble.
"I think many people in the NHS have been taken by surprise by how radical it is and the scale of it," says Nigel Edwards.
"It's a complete intellectual system which looks very much like the way gas and telecoms were deregulated in the 1980s rather than a healthcare reform.
"So we've been confronted with what looks like a very elegantly constructed piece of machinery with lots of cogs and levers and things connecting but we've absolutely no idea what will happen when you switch it on."
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