'After a few cycles in the policy washing machine, you would have thought we would all have come out looking the same colour and trying to iron out the same creases'

I am sure many readers would agree that much has been lost in terms of institutional memory during the three rounds of primary care trust.reconfiguration which have reinstalled the somewhat familiar boundaries of the health authority.

At the same time, many of my GP colleagues lament the stop-start approach to the destruction of total purchasing and the recreation of largely rudimentary practice-based commissioning. After a few cycles in the policy washing machine, you would have thought we would all have come out looking the same colour and trying to iron out the same creases.

I fear not, for the agenda that has been instigated in primary care seems to now be placing us in conflict.with the trajectory emerging from renewed vigour in commissioning. As a general point, primary care has lately been concentrating on three things: mostly, delivering the usual care to patients; financially responding to incentives in the quality and outcomes framework.or enhanced services; and thinking about practice-based commissioning.

One of the clear electoral promises in primary care was to ensure patients had access to the GP services they requested.

Growing pains

The issue of primary care growth serves a good example. Primary medical service contracts were locally negotiated and.established to promote care delivery to reflect need. In many places, the expansion of primary care teams led to the employment of extra practice nurses, enhanced triage services, nurse practitioners and salaried GPs. Quality and outcomes.payments and access-enhanced service monitoring have been used, some more than others admittedly, to further bolster practice teams. These have led to better access and more systematic approaches to chronic disease management.

Now, as we come to the end of large incremental funding growth, PCTs are beginning to look at best value.

Assess to impress

Best value should start with needs assessment, equitable access and assessment of inequalities. Large variations can be found even within the geography of a health authority. These kinds of exercises quickly substantiate a long-held impression that,.since the days of the Black or Tudor Hart reports in 1980 and 1971 respectively, leafier areas have more clinical staff and use greater resources. Access policies have therefore rewarded the most successful practices, which now have larger costs, a bigger staff base and look as though they probably refer more patients on a cost-weighted basis..

The question arises about what follows. The days of directing growth disproportionately at under-served areas are falling behind us but remain the obvious example. We have seen a second year of zero growth in core primary care budgets, even though inflation is running at 2.8 per cent.using the lower consumer price index. So times are getting tougher and, although not raising.sympathy, proactive practices will be making plans for reduced profits and perhaps reducing cost bases, not exactly drivers for clinical engagement.

Extension is key

We all know that the key to improved access does not lie in more staff seeing the same patients more frequently. The answer lies in extended opening, for example Saturday morning and evening acute surgeries, in essence all the things that were put up for sale for£6,000 back in April 2004.

The challenge will be to persuade practices to do more in leaner times. Undoubtedly possible in a few areas. But I would expect to see choose and book go up in smoke in others.

Dr Andrew Jones is a GP in Stamford and policy adviser to Conservative MP.Stephen Dorrell. He is also director of practice-based commissioning.at UnitedHealth Europe.