© Andy Rain/EPASupporters demonstrate against the government's new health and social care bill.
Among the 50 GPs feted by the prime minister in January at a champagne reception in Downing Street were the leading lights of the National Association of Primary Care, a group of family doctors who many see as the brains behind health secretary Andrew Lansley's plans.
The physicians sipping bubbly at No 10 were part of the first wave of GP shadow consortiums - doctors tasked with reshaping hospital services in the runup to finally being handed the NHS purse strings. Treading the corridors of power that chilly winter evening was Charles Alessi, an executive member of the NAPC, who two weeks earlier had penned a tabloid comment piece backing the radical pro-market plans of the government.
While the association is careful to say it is not aligned to any party, it did come up with the central plank of the health secretary's policy: dissolve England's primary care trusts, which currently commission hospital care on behalf of patients, and instead allow GP practices, essentially private businesses run by doctors, to form consortiums to buy treatments using £80bn of Treasury money. The loss of the primary care trusts will see 24,000 jobs go.
For the first time all England's 38,000 general practitioners will, under the government's plans, be directly responsible for access to expensive hospital treatments through referrals. Those family doctors who manage to stay within budget - and perhaps even save the taxpayer money - will get cash bonuses.
Alessi has already been accused by the trade unions of standing by while 500 jobs - one in five posts - are lost at his local hospital in Kingston, Surrey. Unlike most in his profession, the 56-year-old does not recoil from saying that GPs will have to take on a role where they may be perceived to be making cuts in services and take the lead in unpopular rationing or reconfiguration decisions.
He argues that NHS money has run out and to think hospitals cannot change is for "cloud cuckoo land". Alessi says the changes at Kingston are a forerunner of things to come - arguing that in the future, hospital doctors should be fined for prescribing treatments that are not required. As an example, he says the local hospital's orthopaedic department carries out 20% too many hip and knee replacements compared with neighbouring areas.
"If patients have three legs or the population was older then this would be legitimate, but are we any different from Merton or Sutton? No, we are not."
Alessi appears to be gearing up for a fight. He says hospital physicians are "overtreating" people. In Kingston, he says, too many patients are being given drugs that stop elderly people going blind, a condition known as macular degeneration. "If you are overtreating some patients you are undertreating others."
But won't patients revolt if they are not given the medicines they need? "Yes, it is pretty uncomfortable, but we probably perform too many operations on people who should not have them."
Under the coalition's plans the new family doctor will become part accountant, and the best GPs will be the ones who deliver care at an affordable price. Underlying such thinking is a policy equivalent of natural selection - where the fittest hospitals and GP consortiums survive at the expense of the weakest. Under Lansley's health proposals GP practices and hospitals would compete for patients and the best would expand at the expense of poor performers.
Without competition, says Alessi, the NHS has been left in a state of "equitable mediocrity and stagnation". Hospitals cannot all be the same. The result, he suggests, is that the local hospital may no longer be able to offer treatments to most of its surrounding population, and patients will end up moving home to get the care they need.
"In the future people may move for access to drugs. Patients already move to Scotland, which has free care for the elderly."
These are controversial views in healthcare. The former chancellor Nigel Lawson once joked that the English only had one national religion: the NHS. Alessi, and others, are seen by many as heretics.
The two main charges against Lansley's plans are that GPs are not up to the job of spending billions of pounds of taxpayers' cash, and that there is a barely concealed ideological agenda to break up and then privatise the NHS.
These two issues coalesce in the issue of family doctors' pay. GPs are private businesses receiving taxpayer cash per patient. Take away the running costs and the practice profit is in effect their income, which includes selling extra services such as simple diagnostic tests and NHS bonus payments. (The latter have been heavily criticised as about 95% of GPs routinely hit the less than onerous performance targets - and receive annual payments of roughly £25,000. Average GP income is estimated to be £105,000 a year.)
Lansley's bill will see more performance-related pay introduced into the system. Dr Brian Serumaga, at the University of Nottingham, looked at half a million patients with high blood pressure and, in a paper published earlier this year, found that "pay for performance had no discernible effects on processes of care".
"Hypertension is the most common reason for a visit to a doctor in the UK and the money made no difference. It is not a good policy to continue."
But the promise of more money is tempting big business into primary care, says William Laing, an expert on private health. Currently, less than 3% of England's 8,000 practices are owned by corporate companies.
"At the moment GPs cannot compete for patients as the primary care trusts maintain their patient lists. But that is being swept away," said Laing. "We will slowly see bigger companies taking hold."
Many of the health secretary's supporters are pro-private business. Johnny Marshall, the chair of the NAPC, has, along with United Health, a US firm bidding to win NHS contracts, produced a GPs' guide suggesting that private companies could be hired to help commission care. By coincidence, Marshall's GP consortium in Buckinghamshire, serving 200,000 patients, is also called United.
While Marshall did not receive money for the guide, United has paid to exhibit at conferences organised by the NAPC, which pays him. The chair also has a stake in a healthcare company that provides services to the NHS - but says he will "absent himself from decision making because I recognise this may undermine trust between doctor and patient if I were seen to be making money".
These alleged conflicts of interests have become a centre of furious debate. The British Medical Association's Laurence Buckman, who leads the GP council, says the government is "creating an environment where individual doctors could in theory profit from NHS activity. I am not sure this can be made ethically sound."
This view has been privately acknowledged even by Lansley's most ardent supporters. Former Tory health secretary Stephen Dorrell MP, the chairman of the Commons health select committee, met private health companies last June and discussed possible conflicts of interest in the new commercial relationships facing GPs.
The minutes were drafted by 2020health, a "grassroots" group, and sent to Lansley. The organisation is run by Julia Mannning, a former Conservative parliamentary candidate, and is chaired by Tory minister Tom Sackville, who is also a chief executive of a global network of health insurers.
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