Column

The very long history of the PCG

It’s taken a very long time to prise open the private world of family doctor administration, says Charles Webster

Writing in the last issue of healthmatters, Marion Barnes and Martin Evans pointed out that failure to involve individuals in health care decision making has represented one of the most consistent deficiencies of the NHS. They suggested that the imminent transition to Primary Care Groups offered a fresh opportunity to render public participation more effective. This highlights the problem of the ‘democratic deficit’ that has plagued the NHS since its inception. The changes introduced by the internal market made matters worse and, alas, the transition to PCGs may well increase rather than reduce the democratic deficit.

Historians of the future will observe that the idea of a primary care led NHS captured the imagination of planners in the 1990s — but that this was another case of reinventing the wheel.

It so happens that the Dawson Report of 1920, the first blueprint for a modern health service, staked its originality on proposing a primary care led health service. Its central recommendation was for district health services to be located in primary health centres. These were described as institutions ‘equipped for services of curative and preventive medicine to be conducted by the general practitioners of the district, in conjunction with an efficient nursing service and with the aid of visiting consultants and specialists’. Dawson’s primary health centres were conceived on an ambitious scale, being equipped with operating theatres, radiological facilities, pathology laboratories, and dispensaries, as well as being located in spacious surroundings, sufficient for provision of recreation facilities for the local community. If anything, Dawson’s conception of primary care was more ambitious and enlightened than its ‘modern’ PCG counterparts.

In conditions of austerity the Dawson plan was unrealisable, but the primary care concept took root and was embraced by all the important planning documents preceding the establishment of the NHS. For instance, the primary health centre was central to the Report of the Medial Planing Commission of 1942, which was sufficiently optimistic about prospects for implementation that it outlined primary care arrangements in considerable detail.

The failure to build on this primary care concept represents a major failing of the early NHS. The reasons for retreat from this rational and humane vision are complex and difficult to understand with the passage of time, but essentially the ideas of genuine teamwork and possible public employment were abhorrent to the medical leadership of the day. As a result, the idea of a primary care led NHS seemed like an unpardonable threat to medico-political susceptibilities.

This adverse reaction was so strong that it has taken nearly half a century for these fears to subside. The PCG changes of 1999 represent a tentative step back to the ideas of the architects of the NHS. On this occasion the planners have been highly circumspect in their approach and have avoided resuscitating any of the ancestral fears of the medical profession. This accounts for some big differences between the primary care concept of the 1940s and that of today.

During the Second World War planners were agreed that the primary care units should be planned according to populations of not less than 500,000. These were called ‘areas’ or ‘regions’ and it was proposed that local government reorganisation should be undertaken with this objective in mind. It was envisaged that the primary care services would be the responsibility of committees of local government, which would of course contain elected members, but also representatives of the health care professions. A strong professional advisory mechanism was also envisaged. A strong element of public participation was therefore built into the system.

In practice, in order to appease the medical profession, from the outset the primary care administration of the NHS contained the least element of local democratic accountability, and the greatest insulation from the rest of the system. It was not even affected by the ‘Democracy in the NHS’ campaign waged by the Labour government in 1974. The private world of family practitioner administration was not prised open until FHSAs and DHAs were merged. In many respects the PCG represents reversion to the traditional pattern, with power again firmly invested in the hands of the independent contractors, with only limited influence of other health professionals, and token representation of the community. Looking at the present changes in the light of a longer-term constitutional perspective, it can be argued that definitive sacrifice of local democratic accountability is among the concessions offered to the medical profession to purchase its compliance with a primary care led NHS. If this assessment is correct, it seems unlikely that the new system will be responsive to the modest proposals made by Marion Barnes and Martin Evans for reducing paternalism in this vital part of the NHS.