Feature

Progress by chaos?

The two recent White Papers on primary care set a potentially radical agenda for the future. But opinion is divided on the likely effects of change, reports David Glasman

The government did its bit towards a white Christmas by producing a flurry of White Papers on primary care between October and December. But will its plans change the delivery of healthcare permanently and utterly or, like the real white stuff, disappear in the spring leaving the NHS landscape more or less as it was?

The proposals (see box) are an extraordinary hotchpotch. As Michael Walker, director of the NHS Support Federation, points out there is something in there for both Left and Right. The Right will cheer plans to encourage more private investment in primary care through the private finance initiative. The Left will grudgingly support proposals to introduce salaried GPs.

The first White Paper, Choice and Opportunity, was published in October. It sets out proposals aimed at GPs, dentists and community pharmacists, and optometrists. The key aim within general practice is to bring an end to the single national contract agreed between the health secretary and GPs which sets out what primary care services the latter provide. The government claims the existence of a single contract does not allow sufficient flexibility to adapt services to meet local need. In addition, it argues the contract inhibits GPs from working closely with nurses and other therapists.

The second White Paper, Delivering the Future, was published in December. It is a wide-ranging document which puts flesh on the bones of the first document. In the government’s own words it represents ‘a programme of action both nationally and locally into the next century’. It says the paper does not represent a new agenda, but ‘builds on the changes of recent years by giving those closest to the patient — in this case primary care professionals and their teams — a powerful role in improving services’.

The biggest spectre raised in the White Papers is that they open the way for privatisation either directly or by stealth. There are several mechanisms which might allow this: plans to introduce salaried GPs allow them to be employed by ‘other bodies’ outside GP partnerships; and the government is encouraging more private finance to build GP surgeries.

Tower Hamlets GP Sam Everington believes retailers and drug companies will be keen to employ GPs who will then be under insidious pressure to promote their employers’ goods and products. In addition, he argues that GPs may be starved of funds and be forced to occupy premises built with private finance.

The end result, he says, will be an erosion of the trust inherent in the doctor-patient relationship and a loss of the GP’s role as an ‘independent’ gate-keeper to the rest of the health service.

Michael Walker fears privatisation will come because the philosophy informing the White Papers is one of devolution of decision-making to GPs. ‘We are going down the road we took in dentistry in which it will be easy for GPs to say we won’t take NHS patients on our register any more — if you want to register you will have to pay.’

Health secretary Stephen Dorrell has rejected fears about surgeries at Sainsbury’s as well as reiterating the Conservative government’s commitment to an NHS free at the point of use.

Peter Davies, editor of the Health Service Journal, believes that supermarket surgeries will not happen because they hold no real financial benefit to retailers and because the public will not want to wait for a GP appointment while staring at a check-out queue. He also argues there is evidence to suggest that the Department of Health is wary of drug companies having greater control in healthcare delivery.

But some commentators suggest that the two White Papers could have other effects — as yet these cannot be predicted with any certainty but they could be almost as profound as commercialisation of the NHS. This is because the underlying philosophy of the papers is that of deregulation.

The government has called for volunteers to come forward with new forms of primary care contracts to replace the single national contract. It has promised that new contracts will take the form of pilot schemes initially, which will then be evaluated.

Steve Harrison, reader in health policy and politics at Leeds University’s Nuffield Institute for Health, says: ‘This represents the deeper Conservative philosophy of fragmentation of monoliths and a suck-it-and-see approach.’

Despite talk of volunteers and pilots, new schemes could quickly change from being pilots to the accepted pattern of primary care delivery, he goes on. ‘You say it’s voluntary but at the same time you create a bandwagon which everyone has to jump on.’ GP fundholding and trust hospital status was introduced in the same way. ‘There will be a fragmentation of health services which will be irreversible,’ he says.

Angela Coulter, director of the King’s Fund Development Centre, warns the government’s approach could be a dangerous one. ‘You are throwing out the regulations in order to encourage innovation but that’s a high-risk strategy which depends on pilot schemes being rigorously evaluated.’

Dr Andrew Willis, chair of the National Association of Commissioning GPs, describes the government’s approach as ‘the statutory introduction of the theory of progress by chaos’. He fears that the NHS tradition of strategic planning will be lost in the rush to devolve power down to individual GP practices.

The result will be a change in the very nature of the NHS, says the Northampton GP. Planning the spread of resources according to the needs of populations of patients, rather than individuals, would go out of the window. ‘We would still have a healthcare system, but it would not be the NHS.’

But could it be a more equitable system? In its analysis of the need for change, the government itself calls attention to inequalities in the distribution of resources for primary healthcare and problems in attracting GPs to certain areas — such as the inner cities. Some of its proposals are designed to reduce these inequalities.

Dr Alex Scott-Samuel, director of EQUAL, a research unit into health equity based at Liverpool University, says the language of the document is at least encouraging. For the first time the government has used a value-laden word – ‘unfairness’ — rather than a neutral word – ‘variations’ — to describe the distribution of primary healthcare resources.

But it has fought shy of turning words into action by its non-directive approach. ‘The White Papers enable rather than direct any action which allows equity problems to be addressed,’ Dr Scott-Samuel adds.

Ms Coulter says there are mechanisms in the proposals which might mean better primary healthcare services in areas currently lacking good facilities, but there are no guarantees. She adds: ‘I would like to see the government saying more forcefully that it will improve services in deprived areas without cutting services where they are already good.’

The government’s ultimate premise is that it is putting flesh on the bones of the catchphrase that the country is moving towards ‘a primary care-led’ NHS. The introduction to the second White Paper —Delivering the Future—insists the proposals do not represent a new agenda, but build on changes already taking place in the health service.

But Peter Davies believes there are major obstacles in the way of a relentless surge to the hegemony of primary care over secondary care, which the White Papers do little to tackle.

The first is simply that there are considerable clinical limits to what services can be provided from a GP surgery or health centre. Second, although the White Papers make suggestions to improve recruitment to primary care, severe shortages of GPs are likely to continue for the foreseeable future, putting a break on any expansion.

Finally, he argues that although the government has promised some measures to encourage a shift of resources from the acute to the primary sector, the proposals rely too much on a pious hope this will happen. History suggests otherwise, with the acute sector proving skilled at hanging on to its share of resources.

‘I think there is too much reliance on resources shifting from the acute to the primary sector and that’s not going to happen to the extent that will allow the changes envisaged here to take off. It would need “new” money for the NHS.’

Dr Scott-Samuel believes the term ‘primary care-led NHS’ remains a meaningless slogan even after the two White Papers.

He prefers the term ‘primary care centred NHS’ with salaried GPs. But that remains a distant possibility. ‘It would require a big shift of resources, such that primary care became the key focus but there is no suggestion that this is happening or will happen.’

Commentators, then, are divided on the likely effect of the two White Papers. Even more uncertain is what Labour will do with the proposals if it wins a general election. Even if the plans are ditched — and wholesale rejection is unlikely — they may have served one of their political purposes: keeping GPs reasonably happy and, therefore, quiet in the run up to the election.