General Practice and Primary Care

There was little home visiting.  Anticipatory health care, along the lines suggested by Julian Tudor Hart, was increasing and being institutionalized.  For the first time GPs were working for organisations based in the community, with a focus on management, support and leadership - primary care trusts (PCTs). The community nurse caring for chronic disease, the out-of-hours rebellion by GPs who wished for more control over their lives, the desire of younger and part time GPs for a salaried service, modern information technology and new types of contract were destroying it, and the gatekeeper role with it.  Only half the population thought his mattered; many were happy to see any doctor as long as the hours were convenient to them. Constant changes were introduced by government with over the horizon.  In 2007 The Royal College of General Practitioners (RCGP)published a roadmap on the Future of General Practice that analysed the environment in which GPs were now operating and the problems they faced, now that they were no longer the main entry point to the NHS and working within a single model of practice organisation.  The RCGP suggested that GPs should become 'federated' into larger groups to provide a wider range of services such as scans and x-rays and virtually all health problems in the population, including mental health, in primary care closer to patients’ homes. Generalists and specialists would work more closely together to ensure that hospitals were reserved for acute illness, specialised investigations and major surgery.  The document was universally supported by professional bodies, largely because it accepted the wide variety of practice patterns that worked satisfactorily.

A poll conducted for The Times revealed contrasting views of doctors and patients.  Almost half patients thought polyclinics would improve the standard of care and access, and that seeing the same doctor on each visit or in an emergency did not greatly matter.   GPs opposed the idea of polyclinics and argued for continuity of care, even though the latter was an aspiration that in practice could never be delivered. _{(The Times 23 February 2008)}

In 2007 reviews of the NHS suggested further changes to general practice.  Lord Darzi, reporting on health services in London, called for GP run primary care centres (polyclinics) focussed  on walk in services as well as those for registered patients.  His report proposed the opening of a 100 new practices in areas with poor provision. It was probable that these would be delivered by a wider range of providers - some perhaps in the private sector.  One such provider, UnitedHealth, obtained the contract to run three practices in North London. Sainsbury's and Asda  piloted the provision of  surgery space to local doctors in stores in the evening.  The BMA's General Practice Committee and some in the RCGP feared that the strengths of British general practice were being undermined by officials lacking in understanding of primary health care.

New contractual arrangements

From 1948 until 1997 all GPs worked under a single contract for services, nationally negotiated and set out in "The Red Book". The NHS (Primary Care) Act 1997 was passed shortly before Labour came to power and allowed health authorities to commission primary care services from GPs and others within the NHS in new ways.  GPs, instead of individual contracts, had group or practice contracts to deliver a defined package of services.   Contracts were local, rather than national, with a firm linkage to quality; and services could be tailored to the needs of specific groups, such as the unemployed.  Local negotiation of contracts between primary care trusts and the doctors, and local targets, budgets and monitoring, made it possible to test alternative systems for delivering primary and community care schemes and to try our new mixes of skill.  The introduction of co-operative working, 'clinical governance' and unified budgets tended to undermine the independent contractor status.  Partly there was a realisation that the standard contract did not meet the needs of all communities equally well; partly the belief that there should be more competition in primary health care.  In 2003 the Health and Social Care (Community Health and Standards) Act allowed Primary Care Trusts to commission care from "anyone capable of securing the delivery of those services"  It established four contracts

• General Medical Services (the traditional GMS contract as revised between practices not individuals and trusts)

• Personal Medical Services (PMS)

• Primary Care Trust Medical Services (PCTMS) in which PCTs provided services themselves, directly employing staff

• Alternative Provider Medical Services (APMS) in which the PCT contracted with an individual or an organisation, e.g. independent sector organisations such as United Health Europe or Care UK, the voluntary sector, other PCTs, Trusts or even a parallel contract with GMS or PMS practices.

The contract was now between the PCT and practices, companies or subcontractors providing primary care.  The monopoly of individual GPs as contractors was broken. _{Pollock A et al. BMJ  2007;335:475-477 (8 September).}  Personal Medical Services contracts became popular.  The legal basis of practice had changed, and commercial law was now involved in contracts, not public law alone.  In addition, services were unbundled and, instead of a single individual providing everything (in theory), additional or enhanced services such as screening or the care of chronic conditions could be provided by different systems. A number of commercial firms, and some groupings of general practitioners, took advantage of these opportunities.  The private sector could, and did, bid successfully to run general practices.  Because of the expansion of practices both in size and in the range of services offered, when the Quality Care Commission was under consideration, (the new regulator to follow the Healthcare Commission), it was proposed that general practices should register alongside trusts.

Personal Medical Services

If general practitioners were coming to view their role differently, government seemed also seemed confused about it.  The NHS Plan (2000) could be read as implying that much that the GP did could be done by nurses, and GPs might turn themselves into intermediate level specialists as the BMA Unit's report suggested.  General Practitioners and Nurse Practitioners were increasingly specialising in particular aspects of clinical management, education or research. _{Nocon A & Leese B, BJGP 2004, 54, 50-56.} GPs were taking on tasks previously more commonly the responsibility of secondary care, providing such services for patients outside their own practice, and being paid specifically for them.  This development was viewed with approval by the Royal College of General Practitioners (RCGP). Led by the Modernisation Agency, there was a move to accrediting GPwSIs, particularly if they could provide a service that could avoid hospital referral. Health Authorities and subsequently PCTs began to contract for services.  By 2003 there were more than 1250 of GPwSIs in specialties such as dermatology, ENT and cardiology.  Often they worked in fields where there was a long waiting list to see a consultant. The additional equipment needed by GPwSIs was extensive and expensive, costing anything from £10-40,000, and the cost-effectiveness was open to question.  Rapid access to hospital facilities for complex investigation was also necessary.  Several models were developed, fully independent from secondary care, services with close hospital support, services with consultant triage, or fully based in the hospital.  A measure of specialisation appealed to some GPs.  It was clear, however, that such services were an addition to, rather than substitution for secondary care.  GPwSIs represented a new way to configure services, and one within the power of management rather than the professionals themselves.

New organisational structures moved decision making away from the individual doctor. Medically, GPs worked within a framework of increasing clinical guidance, e.g.  evidence based medicine, protocols, and instructions on the use of pharmaceuticals from NICE. 

Primary Care Trusts and commissioning

Structural changes in the management of primary care were now dictated by decisions to change the patterns of financial flows.  In the early 1990s, the Conservative government tried to contain increasing demand and rising costs in the NHS by the purchaser-provider split and the introduction of GP fund holding.  Though voluntary, the number of GPs becoming fund holders was spectacular; by 1998 about 55% of the English population were covered by some kind of fund holding arrangement. Fund holders were energetic, and academic evaluations suggested that they cut elective admissions and waiting times. They drove service reform and led doctors to consider management issues as few policies before, or since.

GPs who opposed fund holding but wanted to help shape secondary care teamed up to advise health authorities and PCTs through "locality commissioning", a model more to Labour's liking.  With Labour in power, fund holders were given a clear signal in December 1997 that fund holding would end in April 1999, and to maintain the influence of primary care on hospital expenditure GPs were brought together to commission all secondary care except mental health services.  In England around 500 Primary Care Groups (PCGs), each covering populations of around 100,000, took over from nearly 4000 health authorities, fund holders, and locality commissioning groups. For the first time since 1948 general practice/primary care, and community care, was brought into a single organisation with a unified budget.  PCGs could operate at various levels of complexity and influence, and were encouraged to move to the most significant, the Primary Care Trust (PCT).  From April 1999 all GPs in England and Wales worked within PCGs that commissioned or purchased secondary care for their populations. All had limited annual prescribing budgets and ring-fenced funds (based on weighted capitation) for providing general medical serv­ices and developing primary care. Their boards consisted of general practitioners, nurses, other primary care staff, and representatives from local authorities and the public.

Primary Care Groups were encouraged to develop into Primary Care Trusts, (PCTs), which were  substantially larger than their predecessor fund holding or commissioning units.  These were not definable in neat geographic terms, the areas being decided by the homes of those on the list of participating GPs. GPs lost influence in the management of organisations that were becoming mini-health authorities, and whose Chief Executives had often worked for the previous health authorities. PCTs increasingly concerned themselves with the complexities of secondary care and their vision of the future was not solely that of their GPs.

Primary Care Trusts began to flex their muscles.  Stronger practice management, the modernisation of premises and their concentration into larger centres perhaps providing wider diagnostic facilities and outpatient services, and a move towards nurses as the first point of contact particularly out of hours, were on the agenda.  Unlike the management bodies of the past, they increasingly influenced the way GPs worked, for example by the introduction of "care pathways". The Bradford PCT, a leader in developing new functions, worked towards "demand management" and "the best use of hospital services".  GP specialists began the triage and treatment of urological conditions (performing cystoscopies), dermatological conditions, "uncomplicated" neurological referrals, musculoskeletal problems, diabetics, and minor surgery (for example vasectomy and 'minor eye surgery'.  PCTs, responsible for implementing the new GP contract could GPs with special interests to achieve their strategic goals, for example the improvement of the care for chronic conditions.  Similarly they might encourage the adoption of PMS contracts, which allowed the Trust greater management powers and facilitated the design of out of hours services, and chronic disease services.  It also made it possible to plan the devolution of commissioning to practice level, giving them financial autonomy.

The wide responsibilities stretched PCT management.  Recruitment of top calibre staff was difficult.  Sometimes PCT mergers were considered to ease the difficulty, or sharing back-office functions such as payroll, or partial or full merger of management teams covering more than one PCT.

Practice-based commissioning

Labour had abolished GP fund holding when first taking office, but a new model of practice based commissioning was introduced in 2005/6 to enable GPs and other groups to play a bigger role in commissioning services for their patients and local populations.  It became policy that PbC should be universal and there were financial incentives for GPs to take part.  From April 2005, practices could hold an indicative commissioning budget from their PCT, to manage the delivery of services for their patients.  Healthcare practitioners other then GPs, such as nurses, could also hold a Practice Based Commissioning budget.  For example community based nursing teams could hold budgets for groups like vulnerable adults. The advantages were said to be

• a greater variety of services from a greater number of providers, closer and more convenient to patients.

• encouragement of clinician to clinical discussion about improving care

• involving practitioners in service development

• a set of levers to aid demand management.

Savings from managing referrals more efficiently would be  reinvested into patient care. The policy had resemblances to fund holding and received a widespread welcome. There would be no personal financial advantages for doctors, and the use of national tariffs would reduce the possibility of hospitals offering "bargain basement" services. GP practices would have incentives to provide x-rays, tests and outpatient consultations within their practice or to commission these services from another provider.   With the implementation of the policy, further guidance on its implementation was issued.