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A new direction

As the monopoly held by GPs ends, new primary care routes are opening to patients
A Martian landing on earth would be puzzled by general practice. Despite enjoying the best pay deal in living memory, record investment in the NHS, an agreement offering self-employed contractor status and a copper-bottomed pension plan, GPs appear to be revolting.

Last month, following a lot of sabre rattling by the Secretary of State, GPs grudgingly voted to extend surgery opening hours to allow patients to be seen after 5pm and at weekends. The government was responding to patients' views that put access to GP services at convenient times as a high priority.

In a speech in March Alan Johnson spelt out his vision for primary care in England, and it does not make for easy reading for poorly performing GPs. However, the good should have nothing to fear.

Speaking to the NHS Confederation Primary Care Network, Johnson, made it clear that on the whole, primary care served patients well because it is based on the personal relationships between GPs and patients.

Despite this praise, he went on to highlight the huge inequalities that exist in the provision of GP and primary care services. A child born in Kingston-upon-Hull is likely to die far sooner than a child born in Kingston-upon-Thames.

Johnson was clear that he intends to tackle this issue head on by ensuring that everyone can access good quality services in primary care land. He aims to achieve this in a variety of ways.

He emphasised the role of GPs and other health professionals in working better with agencies to prevent ill health and promoting healthier lifestyles. He reminded his audience that 42,000 lives could be saved annually if people ate fruit and vegetables daily; 20,000 lives could be saved if people ate less salt and billions of pounds would be freed up if people undertook more physical exercise.

It is obvious that a GP cannot prescribe a change in lifestyle, but there is evidence (as in Sheffield) that GPs who actively engage with other agencies can impact on health improvement in deprived populations.

This suggests that the GP of tomorrow will spend less time treating illness and more time assisting people to take charge of their own health and self manage their risks.

Johnson also wants to see far greater flexibility in how and where services and advice are provided. He cites the example of heart health teams in Birmingham that are going out to football clubs and children's centres to reach target populations. He also suggests that GPs might consider offering a ring-back service whereby a GP will telephone a patient who is unable to get a convenient appointment time. Some practices are already operating in this way and it is clear that the minister wants many more to do the same.

As part of the Darzi review an investment of £250m for the most deprived PCTs was announced. This money will be used to provide 100 new GP practices. Some of the most deprived communities seem to be the least attractive options for many GPs, leaving them poorly served by traditional practice models. It is clear that Johnson will happily see this money go to traditional GP services that are prepared to move into such areas, but he is equally happy to see competition from either the private or not-for-profit sectors.

We have already witnessed Sainsbury's offering GP services in one of its big stores; an American-led private company is already operating GP services in Derby and elsewhere, and Richard Branson and the Virgin Group are seriously eyeing the primary care market.

If the minister wants competition, there are plenty of providers in the world that will happily deliver this for him.

Smart GPs will seize opportunities; the not so smart and downright useless had better wake up and smell the coffee. The once sacrosanct monopoly of GPs in primary care is rapidly coming to an end.

Johnson pointed out in his speech that patients are not too fussed about who provides a service, they simply need to know that it is free at the point of need, easily accessible and of good quality. I suspect he is right. I have a perfectly OK GP, but I have often used the NHS walk-in centre in Soho or the private walk-in GP service on Victoria Station as they both offer me a great service, at my convenience and, in the case of the private clinic, reasonable value for money.

The traditional GP service may not always be best for all patients or communities. We won't necessarily see a revolution in GP provision, but Johnson is clear that he will look to alternative providers to challenge some long standing inequalities experienced by poorer and more deprived populations.

His real vision lies in his hope that beefed up commissioning by PCTs, (aided by private sector support from the Framework for External Support for Commissioners), which has been piloted in a small number of PCTs, is now to be opened up to all. He was clear that, in his view, a PCT must have the ability to remove contracts from GPs who are not providing good quality services. PCTs have been reluctant to use some unclear powers to do this and Johnson wants it to happen with private sector advice to PCTs.

Johnson knows when patients can easily access GP surgeries, hospital admissions are fewer, less drugs are prescribed and patient satisfaction is higher.

He emphasised the need for community pharmacists to play a greater role in order to augment GP services. He promised a new white paper on pharmacy services, which may change things dramatically. This white paper will suggest that the pharmacy in the high street should become a healthy living centre offering a wide range of new services including treatment for minor ailments, screening, routine testing, advice on taking medicines and better support for patients living with long-term conditions such as asthma.

The white paper will go out for consultation, probably in the first half of this year. Many of the big high street chains providing pharmacy services will relish the prospect of taking on a greater role in healthcare, and entrepreneurial small stores will grasp new opportunities.

The speech spells out that change in GP and other primary care services is inevitable. The minister is also supporting a GP practice accreditation scheme being piloted in around 40 practices by the Royal College of General Practitioners. Johnson clearly expects this scheme to be rolled out across the country.

In short, accountability and scrutiny of GP services is to be better focused and, where GP services fall short, contracts will be removed and/or alternative providers will be encouraged to bid for NHS contracts.

As if this were not enough, March also saw the publication of a new order in parliament allowing important changes at the GMC. One of the key parts of this order heralds the introduction of appraisal and revalidation for all doctors in the UK, including GPs. Assuming the order goes through parliament without a hitch, revalidation to practise for doctors will go live next year. This will, again, increase the accountability and scrutiny for all GPs in an attempt to drive up quality.

Times are changing in primary care and the pharma industry increasingly will need to think about likely new customers in this changing world. Good GPs will remain key customers, but many other potential providers will be using medicines, other products and marketing strategies to reach these new customers and offer them support where it will be needed.

The Author
Ray Rowden is a former special adviser to the Health Select Committee and an independent health policy analyst.

10th April 2008

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