Review

The personal is political

Personal medical services pilots – Modernising primary care?
Edited by Richard Lewis, Stephen Gillam and Clare Jenkins
King’s Fund,2001. £14.99

The first wave of personal medical services pilots has been live for more than four years and this timely book aims to share the lessons emerging from the initiative.

PMS is one of the less publicised elements of the government’s modernisation agenda but is probably as important as any. It can best be interpreted as an anti-trust measure aimed at the individual monopoly of independent GPs, the corporate monopoly of the medical profession to negotiate contractual terms, and the structural monopoly of the medical profession in providing primary care leadership. The objective of PMS is to break down interprofessional boundaries and local contracting in pursuit of greater flexibility in the provision of services.

Professionalism is, of course, a conspiracy against patients, but it can also be a conspiracy against its own members by constraining their ability to tailor services to specific needs. NHS modernisation requires the conversion of independent-minded professionals into accountable healthcare technicians, in particular GPs, whose independent contractor status is symbolised by that other little Red Book.

So what has been achieved? This King’s Fund study of a selection of PMS pilots supplements a national equivalent involving a controlled trial matching PMS and non-PMS sites. Both studies, disappointingly, found little strong or consistent evidence of a ‘PMS’ effect on quality as they measured it.

A key feature of PMS has been the rise of the salaried GP, a type of post that may well help to alleviate the recruitment crisis facing primary care. Interestingly, trust-led pilots have experienced significant staff turnover compared with traditional GMS practices. This could be an advantage, however, in that clinical staff do not have to make a commitment for life, something that is likely to be particularly important in the pressurised environment of inner-city practices.

Despite the lack of clear of evidence of measurable quality benefits, PMS is clearly here to stay because it not only promotes the government’s NHS modernisation agenda but permits the blurring of the private/public interface, so important to its conception of public services.

My hope is that it will provide a framework for a cooperative model of personal medical services, which is more likely to succeed in primary care than in the much more difficult area of secondary care. And if we can include a contractual commitment to taking on the broad health and well-being agenda at local level – at least in rural areas where this makes sense – so much the better.