GP leaders have called on the coalition government to drop the Health and Social Care Bill and "enter into productive dialogue" to agree a way forward for clinically-led commissioning.

The central concept of clinically-led commissioning is one which many GPs support, and it does not require legislation, writes Dr Laurence Buckman, chairman of the British Medical Association (BMA)'s GP Committee (GPC), in letter sent to all GPs in England.

"When the GPC was originally told about the government's plans for clinically-led commissioning, we welcomed them," he says, but adds that, "over time, it has become clear that this is the most top-down reorganisation the NHS has seen since its inception." 

Through a new network of bureaucracy, the NHS Commissioning Board is directing operations from the centre, Dr Buckman tells GPs. Clinical commissioning groups (CCGs) "do not have freedom to do much as their personnel are being proscribed along with their commissioning support services, their structures defined and their budgets are too small for them to function without uniting into very large and remote units. The ability for ordinary GPs to change things will diminish," he warns.

In his letter to the GPs, Dr Buckman also outlines a range of other concerns with the Bill, including:

- that CCGs could become the vehicles for turning the NHS into a competitive marketplace, where services have to compete for their business and patient care becomes increasingly fragmented;

- the potential for commissioning to be controlled not by clinicians but by private commissioning support services (CSS), operating outside of the NHS, which could end up not only running the "back office" functions for CCGs but also disempowering them and becoming the "de facto CCG management;"

- proposals for a "quality reward" - an incentive for CCGs if they are deemed to have commissioned "well" - "ie, cheaply" - which could cause irreparable damage to the relationship which GPs have with their patients; and

- GPs being blamed by their patients for having to close services for financial reasons.

The BMA urges the government to work with it to develop an alternative way forward, by: - putting GPs into the driving seat of Primary Care Trusts (PCTs), even if they are now clustered; - dropping the "unwise" attempt to force competition onto the NHS; and - reforming the NHS so that clinical need, not commercial interest, is paramount.

"None of this requires a bill," Dr Buckman writes.

He also stresses that, at this stage, the GPC is not advocating that colleagues in CCGs "walk away from the process," that it recognises it would not be reasonable to remove the new structures that are now in place, and that it will continue to issue advice to GPs on how to make clinical commissioning work.

However, at its meeting last week, the Committee formally reaffirmed its opposition to the Bill, which it believes to be "complex, incoherent and not fit for purpose, and almost impossible to implement successfully, given widespread opposition across the workforce."

GPs' participation in CCGs does not equate to support for the bill, the GPC meeting agreed, and it declared its support for clinically-led commissioning, which it believes will not only lead to improvements in patient care in the NHS but that this can be more effectively achieved without existing legislation.

"We urge the government to listen and act on the concerns of GPs in the interests of the future of the NHS and what is best for patients - there is a sensible alternative to proceeding with this bill," Dr Buckman writes.