Feature

A new kind of primary care

Labour’s reforms of primary care move the NHS away not only from the entrepreneurialism of fundholding, but from 50 years of individualism in general practice, argues Richard Lewis

Labour’s plans to ‘modernise’ the NHS contain a number of ‘big ideas’ – high profile innovations that stamp health policy with a distinctive New Labour feel. Traditionally, governments have focused their attention on the hospital sector which has, up to now, been the most politically potent health arena. But in Labour’s ‘new NHS’ many of the big ideas have centred on primary care. In its first two years in government, Labour has launched primary care groups (soon to be followed by primary care trusts), NHS Direct, walk-in and healthy living centres and personal medical services (PMS) pilots.

Primary care policy has been driven by a number of imperatives. First, Labour has been eager to provide an antidote to the perceived inequities and maverick nature of GP fundholding. Second, GPs and community nurses are to be put in the ‘driving seat’ of health services planning and development. Third, mechanisms for clinical quality assurance have been instituted within primary care in the form of clinical governance, supported by new central agencies such as the National Institute of Clinical Excellence (NICE). And last, while the government has publicly supported the role of primary care, it is prepared to challenge the traditional way in which it has been provided. Tony Blair’s recent description of the BMA as a ‘force of conservatism’ makes clear that Labour will not necessarily rely on consensus in implementing its vision for primary care.

In England, PCGs (consortia of GPs and community nurses) have been the most visible and all-embracing of the new initiatives and, unlike previous primary care innovations, participation by GPs is compulsory. These new organisations have been assigned three main roles: to improve the health of their populations, to develop primary care services and to commission hospital and community health care. PCGs are expected to evolve over time to form independent trusts (PCTs), the first tranche of which will emerge from next April. PCTs will have the option to directly provide services as well as to commission them.

Yet, despite the Labour government’s early rhetoric about a ‘third way’ for the NHS, to what extent is primary care policy a departure from what went before? In fact, Labour policy on primary care retains many of the features associated with the previous Conservative administration. The importance of the GP as commissioner of services and allocator of resources, established under fundholding, continues to be a keystone of policy. As with fundholding, practice based budgeting and incentives are encouraged. GPs can retain budget surpluses for the development of their practices (although this freedom is subject to rather more limitations than before). The development of the larger groupings of GPs under PCGs can be seen as the natural evolution of experiments such as total purchasing and GP commissioning pilots established in the final years of the last government. Clinical governance within primary care, while new, remains firmly within the remit of professional self-regulation that has been characteristic of the NHS since its inception.

But while policy continuities may be obvious, there are also some important differences. The emphasis on the primary care development role of the PCG reflects a growing disquiet with the variable quality of primary care that has always been evident, but little challenged. In London, for example, despite numerous inquiries into primary care and substantial extra investment through the London Initiative Zone, many parts of the primary care infrastructure still lag behind that of the rest of the country.

By assigning the responsibility for developing primary care to PCGs, government has finally lost patience with the management-led approach and is seeking to harness peer pressure to force recalcitrant GPs to step into line. This tougher approach to ensuring quality by government mirrors that of the profession itself as it moves inexorably towards periodic revalidation of all GPs. Both have been affected by growing public criticism of the quality of the professionals who serve them. Peer pressure may also be supplemented by public exposure as PCGs are increasingly releasing information into the public domain.

The government’s ‘third way’ treads an uneasy balance between centralisation and decentralisation. For primary care, it may be that this balance has shifted significantly towards the former, with new forms of external regulation soon to be in force. PCGs are accountable to health authorities through annual accountability agreements. At national level NICE, together with emerging national service frameworks (agreed service standards and protocols in major care areas), are beginning to constrain the clinical discretion of primary care professionals. The Commission for Health Improvement (a new statutory body to monitor standards) can be directed by the secretary of state to investigate persistent performance problems within local organisations, including PCTs. The price of self-determination within primary care may be a greater degree of accountability than has ever been experienced before.

One of the most significant policy departures is the challenge presented by Labour to the traditional culture of general practice. The dominant image of the GP has been one of an autonomous individual. This was perhaps exemplified by the stereotype of the GP fundholder and formed a potent symbol for Labour in opposition. Under a regime of PCGs, a new culture of collectivism and corporate values is being promulgated. Now the emphasis is on the team player, and with shared responsibilities and pooled budgets the actions of GPs within the PCG are interdependent.

How successfully this new identity can be grafted onto the old is open to question and some PCGs have struggled to find willing GPs to join their board. The move to PCT status has met with even more cynicism. The governance arrangements for trusts, in particular the appointment of a lay chair and non-executive directors, has been seen by many as a crude attempt to smother any professional independence at birth.

If GP culture is being reformed, so too is the basic organisational structure of general practice. NHS Direct (discussed elsewhere in this issue) and the new ‘walk-in centres’ provide a direct challenge to the traditional model of family practice. Patients are increasingly being offered a choice of routes to primary care, based on an evolving strategy of ‘demand management’ and, in particular, the substitution of nurses for GPs.

Given a context of local crises in GP recruitment and retention, an inexorable rise in demand for services and the increasingly long waits for patient appointments, Labour has argued that fresh ideas are long overdue. Their ideas may prove attractive to patients – after all, most people value choice and speedy treatment. But this policy may prove misguided. One hallmark of traditional primary services is the continuity of care provided through patient registration and the development of ongoing relationships with doctors and their teams. This may be undermined by a plethora of alternative providers and rapid access may not necessarily yield the same quality of care. The problem of access appears to be one of capacity within traditional general practice. One must question therefore the wisdom of establishing an alternative service in preference to tackling the problem directly at its source.

Of course, by establishing alternatives the government has signalled that it does not have to rely on traditional general practice to achieve its aims. This policy theme is also evident in the development of personal medical services (PMS) pilots. The legal framework that gave birth to these was one of the final acts of the Major government and was based on a ‘listening exercise’ in which professionals were invited to advise on improvements to the role and structure of primary care. While they were designed by Conservatives, the pilots were put into practice by Labour as part of the ‘new NHS’. PMS pilots replace the national GP contract (negotiated between the secretary of state and the general practice committee of the BMA) with a local contract (and budget) agreed between a health authority and the pilot. The infamous ‘Red Book’ that describes the myriad ways in which GPs are paid becomes redundant. PMS pilots have introduced a salaried alternative for GPs and in some cases have introduced ‘nurse-led’ rather than ‘GP-led’ primary care. With the second wave now underway, almost 400 pilots are leading PMS into the mainstream.

Labour has set in train a number of changes to primary care, each with the potential to lead to radical reform. Yet, taken together, it is still not clear what the final destination of policy travel will be. Cynics argue that the independent contractor status of GPs will disappear in favour of a salaried service. This seems unlikely in the medium term, although salaried practice is undoubtedly set to increase substantially. Primary care trusts are only just getting off the ground, and in small numbers. Whether these will introduce managed care along US lines remains to be seen. And what of existing community health services trusts? The more bullish commentators propose that they will soon disappear, broken up and absorbed by emerging PCTs. Others defend the highly specialist services they provide alongside community nursing. Labour may have introduced a new structure for primary care but how this develops will be left to local professionals and managers to determine.

Certainly, traditional general practice seems likely to change over the lifetime of the government. NHS Direct, walk-in centres and PMS pilots all introduce a new style of practitioner. Where these are doctors, they sit outside the formal negotiating machinery between government and the medical profession. This has begun to end the monopoly of the independent contractor in the provision of primary care. Whether this is a deliberate ‘divide and rule’ policy or simply the outcome of a number of pilot initiatives is something for the many conspiracy theorists within the NHS to debate.