Keep GPs in the driving seat.

of being doctors “who have dropped off the hospital ladder, but it is foolish of them in the extreme to seek their revenge in their happiness at the destruction of consultants’ power.” Dr Bamji has the admirable quality of saying exactly what he thinks, but in this case it is also what a lot of other consultants think. The problem with this view is that you can’t have a purchaserprovider split and be on both sides of it at once. Hospitals are unequivocally providers. GPs are too, but their interests are less bound up with the preservation of a particular service or hospital. Their focus is on patients, not specialisms. Commissioning is worth the candle only if it can create change. In private industry, 60% of innovation is driven by providers falling out of the market and being replaced by others. Only 40% is internally generated. Commissioning needs to make possible this kind of disruptive innovation. But that means hard decisions, less likely to be taken if commissioning consortiums are not given the maximum freedom possible and the minimum number of constraints. The NHS Confederation seems to agree. In its new paper The Right Reform for Patients it argues that while there should be effective input from specialist clinicians, clinical advice should not be confused with governance. “So there should not be a requirement to include representatives on the boards of the commissioning consortia from the acute sector or the royal colleges . . . there is merit in maintaining a strong primary care perspective in the commissioning process.” Commissioning has so far proved a weak reed. Commissioning without effective competition will be weaker still. To believe that GPs are bloody minded enough to make it work is a long shot, but it is one part of Mr Lansley’s plans that deserves to be preserved. Nigel Hawkes is a freelance journalist, London [email protected]