The issues do need exploring. Who are the best people to design services? And who are the best people to run them? To what extent can we trust individuals and organisations who have a vested financial interest? Are the systems under regulated, or overregulated?
For the sake of their patients and population, GPs analyse the health need, and the provision of existing services, and identify where the gaps are. Local providers may have services that fill the gap, but that are too remote. Or they may have services that fulfil the patient needs of 10 years ago, but are no longer finely tuned to today's needs. Services need to be brought closer to the patient home, especially as modern understanding and technology makes it clinically effective to do so – it's good for patients, it's good for clinical outcomes, and it's good for finances.
GPs use a variety of tools and support services to identify the gaps, and the analysis is subject to scrutiny. Where GPs design and provide the health services that fill the gap, they can't just go ahead and spend money with themselves, it has to go through an exhaustive procurement process.
And yet, we claim that there is a conflict of interest! Are we surprised when patients choose the services that are designed around their needs, in competition to services that are outdated, or too difficult to access? It is probably inevitable that a service designed for a specific purpose will attract users who want that specific purpose; it is probably inevitable that GP-designed services are more popular with local patients.
The sheer complexity of different specialties in hospital care, and advances in what can be done, make it impossible for general practitioners and family doctors to keep up with what's available. Some specialties, like orthopaedics, routinely use the first outpatient appointment as a triage service; the patient arrives and their case is reviewed, and they are then referred to a specialist consultant or surgeon who provides the treatment.
Outpatient appointments are expensive. We want triage a service, which can examine the referral itself, and cut out that first triage outpatient appointment by sending the patient directly to the right specialty.
Who better to do this than someone who knows? If referring to a specialty was as simple as following an algorithm, then general practitioners will be able to do it. We need a team with clinical expertise, and knowledge of what is available, and it is perhaps inevitable that the team comes from one of the providers of the same services.
Not for nothing are our hospitals, mental health organisations, ambulance services, and community care organisations called "Trust".
I don't think it probable that most organisations will put patient care on a back seat in order to maximise their income. Yes, we all can think of examples of individuals and organisations who do this routinely, but they are in the minority. Few (in the UK at least) would provide unnecessary medical interventions – assaults on the patient’s physical body – because of the extra income it generates. Few, in all conscience, would recommend that patients go to the wrong service, just because it makes them richer. Perhaps, we need to accept that the GPs are the best people to design patient services, and that the hospitals are the best people to provide the triage team, and to trust a little more.