Those pressing for the NHS reform risk register to be published argue not to do so denies the public the opportunity to make up its own mind about whether the risks of health secretary Andrew Lansley’s NHS reforms are those worth taking.

But, hold on a minute, what sort of content would you imagine a risk register includes? Yes, worst case scenarios in the NHS inevitably speak of lives lost, patients denied care and treatment rationed. Risks by their very definition are possibilities of suffering harm or loss, or danger. Are we, or, perhaps more pertinently, is our media, able to have mature debates about such matters? Isn’t this exactly the sort of document that should be made available in the public interest?

Well, frankly, no.

Does risk inclusion mean such events will happen? No. Would publication make civil servants less likely to document such risks in future? Quite probably. Would that deny ministers the opportunity to base their decisions on all (however glass half empty) opinion available? Yes.

The battle to have the risk register published has been an interesting story to cover but Labour should now draw a line under that particular report and let it gather dust. Mr Lansley has even published some elements of it now to counter lack of transparency accusations.

With a coalition government still at the helm and a Health Act now passed, we appear to be well on course to finding out whether the ‘risks’ the register contains will actually be realised.

Although, non-publication means most of us will never actually know for sure.

Mr Farnsworth explained that what mattered to patients was the ‘right care in the right place at the right time’ and that best serving ‘Mrs Smith’ was at the heart of what his beacon, providing both health and social services, was aiming to do.

Acute bed numbers had fallen locally, he admitted, with an emphasis on care in the community nearer homes but Mr Farnsworth emphasised that although there were fewer beds existing secondary care wasn’t destabilised because the charge for their use had increased because it was working more intensively.

The conference heard many different examples of integrated care from existing organisations partnering to merging into a single operation. Funding might be shared. Or integrated care could consist simply of better co-ordinated care for patients who would enjoy more seamless treatment. Dame Barbara Hakin, the NHS Commissioning Board’s national managing director for commissioning development, said there was ‘no one size fits all’ answer.

With the social care White Paper expected in the coming months, who would bet against integrated care being at its heart?

According to NHS Alliance chairman Dr Michael Dixon health secretary Andrew Lansley mentioned it 10 times in his speech to 150 clinical commissioning group (CCG) leaders in London on Tuesday. It is the one promise the meeting had been wanting to hear all day.

In fact former National Association of Primary Care chairman Dr Johnny Marshall had identified the wish for autonomy as the meeting’s number one priority earlier in the day.

It would be naive to assume that the autonomy CCGs desire will always be the autonomy Mr Lansley has in mind for them. There was tension earlier in the day when NHS Commissioning Board chairman Professor Malcolm Grant said there would be ‘enormous opportunities for local initiatives meaning there will be variation’, while the Board’s national managing director of commissioning development Dame Barbara Hakin said it was important for CCGs to remember that patients were keen on the ‘N’ in ‘NHS’ and didn’t like postcode lotteries.

It might have been a trick of the light but I thought I caught the health secretary blushing as Dr Dixon bid him farewell. Dr Dixon told the health secretary: ‘You have been an extraordinary advocate for clinical leadership, localism and have taken a lot of stick over the last year. Speaking as a doctor, I’d say you’re looking surprisingly well. I’d like to offer a vote of thanks for putting your career and reputation on the line.’

How often in the last 12 months could the health secretary have received such a welcoming reaction from a medical audience?

And as he told me the story of how he came to be there, I couldn’t help but think what a brilliant example he is of how exemplary NHS care can be; from the GP who realised immediately how ill he was and called an ambulance to take him to hospital, to the nurses who allowed my family to flout the two visitors only per bed rule (my sister and her husband-to-be had travelled 100s of miles to be there).

I remembered a conversation I’d had with former health secretary John Reid years earlier about his frustration with a media which concentrated on the 1 in a million problems with the NHS at the expense of the everyday stories of professionalism and expertise which, fingers crossed, will see my dad leaving Frimley Park today with a spring in his step and a newly fitted pacemaker: a story unremarkable in the big scheme of things but of huge importance to my family and me.

Journalists inevitably focus on the unusual (the Shipman case, for example, so untypical of GPs) but there’s no reason why, as Mr Reid suggested,  we can’t tell the good stories too, which is why I’m blogging this.

Do we need the Health Bill which gained royal assent yesterday? It’s probably a question for a different blog but I pose it here because there’s no doubting the coalition government’s ambition to build on the best of the NHS and improve what it is: a national health service of which we can all be proud.

Will ‘home’ practices risk becoming destabilised if their commuter patients are seen elsewhere? Will city practices be able to cope with a sudden influx of the mobile unwell? Do the IT systems exist to enable the sharing of patient records between practices?

As far back as 2009, the then RCGP chairman Professor Steve Field memorably denounced the idea as ‘crazy‘ during the annual RCGP conference in Glasgow despite DH claims that the college backed the plan.

The GPC has also warned that allowing patients to be seen by practices near their place of work rather than only those near their home address would be complicated to implement, more expensive than current arrangements and unwise in the NHS’s current financial situation.

However in January health secretary Andrew Lansley revealed choice pilots would begin in London, Manchester and Nottingham from April and practice enrolment would be voluntary.

Struggle to recruit practices
LMCs initially warned that the pilots would struggle to recruit practices. Yet at a time when practice funding is tight, it’s perfectly reasonable for GPs in those areas to be considering how they might benefit from the extra £2m funding available.

This week, GP reveals that practices are considering pulling out of the pilots because of the lack of available detail as the April launch draws ever closer (see related articles).

At the time of writing, GP was told the guidance that practices are crying out for was ‘imminent’. Do keep an eye on our website GPonline.com for the latest news.

If it has been published by the time you read this, all well and good. If not, it would appear by alienating practices interested in a controversial government policy, Mr Lansley has succeeded in scoring another spectacular own goal.

The mood was determined and upbeat. There was no doubting the enthusiasm with which the prime minister threw himself into proceedings, he spent up to an hour having his photograph taken with all of them in what he described as his ‘modest Georgian home’.

Conspicuous by his absence was BMA chairman Dr Hamish Meldrum but through no lack of an invitation. As the first cracks in Health Bill support began to emerge, he was unable to attend because of a BMA Council meeting which had voted for a special meeting to discuss the impending legislation.

Fast forward a year and the BMA and RCGP weren’t even invited to the latest number 10 health summit as Health Bill opposition grows. Guests reportedly still aired many of the concerns that representatives of the BMA and RCGP might be expected to raise.

Afterwards the BMA aptly described the summit as ‘selective listening’. It is exactly this sort of childish behaviour that will antagonise GPs further and go no way to persuading an increasingly sceptical public that the NHS is better off in the coalition government’s hands.

A better strategy would be for Mr Cameron to articulate more clearly the successes that clinical commissioning groups (CCGs) are already enjoying, establishing common ground with the BMA and RCGP and continuing to seek to convince them of the merits of his plans. Or at least parts of them. An invitation for BMA and RCGP representatives to be in the room at future such summits would be a start.

Mr Cameron will find that he won’t have to shout quite so loudly about the merits of his plans if he can quietly convince more GP bodies of his Bill values.

For some, this will be a chance to truly reflect the local needs and differences of distinct patient populations, for others it will be the end of the national health service.

The point was raised last week by Guardian columnist Polly Toynbee, who suggested that once the CCGs take charge, local levels of accountability will fall and the founding principles of the NHS will be at risk.

She was speaking at a debate in London organised by the Nuffield Trust on whether the NHS should restrict its offering to a smaller selection of services in order to cut costs – overt rationing as opposed to the usual covert forms.

Passions ran high, and if there were any CCG board members in the audience, the event would have been a foretaste of what is to come in their local areas – the battle over the Bill in parliament is just the beginning.

The new boards will have a far greater public profile than the faceless PCTs. There will be far more interest from the local, and national, media, and there will be much higher expectations of ethical probity.

GPs leading the revolution will need their moral compasses close to hand – and not just within the workings of their own group. They will have a duty to shine a light into the darker corners of the institutions from which they commission care, or risk being blamed for the transgressions of others.

If this is what happens, then the localisation of the NHS could be a breath of fresh air. GPs who have worked in the local systems for years will know where the bodies are buried. They will want to clear the decks, and, hopefully, they will want more public debate on the big ethical issues.

By doing so, they will begin to truly engage their populations, and the difficult decisions they face will not have to be taken by a few tortured individuals in smoke-filled rooms, but in public and in broad daylight. And the burden itself will feel much lighter as a result.

Read more: NHS rationing must be based on spending rules not treatment blacklists

One hundred years after its birth, is it, and LMCs (some of which are slightly older) fit for purpose?

Whatever your thoughts about the Health Bill, one undeniable consequence is that it gives GPs greater control over clinical commissioning groups (CCGs), the bodies designed to replace PCTs.

Speak to LMC representatives and they will tell you that ahead of CCG authorisation they are pulling out of involvement with CCGs, to enable them to speak with an independent voice and to avoid any accusations of conflicts of interest.

In the new order, commissioning GPs will have these potential conflicts of interest to consider and LMCs will play a vital part in promoting the best interests of the GPs they represent.

CCGs seeking to address practice variation could easily slide into the sort of behaviour synonymous with PCTs; target setting and punishment based on poorly conceived ideas of what brings about ‘good’ and ‘bad’ performance.

Reforms pit GP against GP because so many managers have been removed from the bodies that are becoming CCGs. It is imperative for GPs to have representation in any argument with a CCG, and who better to do this than the LMC, which will be forging a good working relationship with the CCG? Perhaps these debates will not be quite so adversarial, with GPs on both sides.

The possibility of an end to the UK-wide contract, which becomes ever more likely should Scotland become independent, also means the GPC will have a great deal to consider to maintain the unity and strength that representation of a larger number of GPs brings.

Who would have dreamt that the GPC and LMCs would be as relevant in 2012 as they were 100 years ago?

There’s no shortage of guidance for CCGs but hard and fast rules from the coalition government have been thin on the ground, perhaps unsurprisingly given natural Conservative opposition to unnecessary red tape.

The Co-operation and Competition Panel last month ruled that: ‘The involvement of NHS Peterborough of two clinicians in lead, influential roles, in a service reconfiguration consultation process was not appropriate in circumstances where those clinicians were associated with providers that would be directly affected by and might gain from the process.’

But as was discussed at a Nuffield Trust event operating under Chatham House rules I attended this morning, isn’t the whole point of the Health Bill that because of their inside knowledge GPs are best placed to be involved with such decisions?

The Nuffield Trust debate did contain some tips for GPs and CCGs about how they might operate most effectively in such an uncertain world.

* You may have involved yourself with the CCG to help its development but withdraw from it if you want to be free to criticise it and from conflicts of interest accusations.

* If you remain, aim not to minimise conflict of interest risks but for excellent commissioning. Be open and honest. Involve patients and the local press in the decision-making process.

* Refer decisions to an independent CCG sub-committee. CCGs would still be responsible for the decisions they take but basing them on the recommendations of a sub-committee would ease conflict of interest fears.

* Think big. CCGs which represent larger populations are far less likely to find themselves accused of conflicts of interests purely because the pool of GPs able to be involved in decision-making is so much larger.

It was a fascinating debate which included the fear that CCGs might tender services as a knee-jerk reaction to avoid conflict of interest accusations. This might be a consequence of reform but surely not something the government would intend, given the cost and time involved?

Another tricky question posed was when is it acceptable not to tender? What should CCGs do if they would prefer to try to improve their existing primary care population without the disruption that competitive tendering causes?

GP’s Commissioning section has covered the  conflict of interest guidance available but look out in the next few weeks for an article looking at the possible pitfalls, exactly what happened in Peterborough and its ramifications.

It’s probably one of health secretary Andrew Lansley’s biggest nightmares as the number of CCGs (currently 240-ish and ever dwindling) plunges towards 152 (the number of PCTs there were when it was decided CCGs would replace them).

One of GPs’ main fears about CCGs is that they would replicate the sometimes heavy-handed attitude of PCTs towards GP performance management.

Well, fear not. I was listening to an NHS Institute for Innovation and Improvement ‘webinar’ this week during which a CCG leader said the £25 per patient government cap on CCG management would inhibit this role.

The £25 cap does seem to have been a bit of an own goal for the health secretary. Its low level means CCGs with populations of less than 100,000 are under pressure to merge (see GP’s Commissioning section for a feature on that very issue later this month) and it’s also hampering the CCG role in improving quality in general practice, although the latter might actually be welcomed by some grass-roots GPs fearing a repeat of PCT heavy-handed mistakes .

A cap that is too low for many with consequences including rendering CCGs unable to represent the population they think is most apt, reducing their numbers as a consequence and opening the government up to the accusation it’s caused all this NHS turmoil for nothing.  While at the same time making general practice quality improvement more difficult.

Perhaps that’s two own goals?  Well played health secretary!