‘Mr Brown has chosen an issue that explicitly requires him to choose sides: patients v professionals’

Gordon Brown has chosen a voter-friendly topic for his debut NHS campaign: the need for better access to primary care. ‘We need more access to doctors, we need drop-in centres, we need local healthcare centres to be more effective, we need NHS Direct to be working,’ argues the prime minister-in-waiting.

He is right about this. Anyone who has been confronted with a feverish child out of hours knows how frustrating it can still be to try and access the health service appropriately.

Call NHS Direct and too often these days it is NHS inDirect - a nurse not available and a call back offered ‘in half an hour’.

Try the GP deputising service and you are often told to go to accident and emergency. Try and find a walk-in centre in central London on a weekend and it turns out many are closed or don’t treat children. So despite your best efforts, you are forced to go to A&E.

But, as the saying goes, ‘to will the end is to will the means’. And the means Mr Brown deploys to solve this access problem will be illuminating. That’s because what might seem rather prosaic is, in fact, a microcosm of the key dilemmas facing would-be reformers of the NHS.

It exemplifies a clear conflict between the preferences of patients and the preferences of GPs - who have campaigned hard, and successfully, to curtail their accessibility to patients.

In the mid-1990s they forced the last Conservative government to amend their contract so individual GPs could opt out of providing out-of-hours care.

Then in the middle of the 2001 general election, the British Medical Association successfully threatened that GPs would resign from the NHS en masse unless a new contract allowed them to transfer their personal responsibility for organising out-of-hours care to primary care trusts.

And then, flush from the proceeds of that new contract, which came into force in 2004, many practices have now given up Saturday morning and evening surgeries altogether.

So at precisely the time when unions are calling for a more producer-friendly stance from the government, Mr Brown has chosen an issue that explicitly requires him to choose sides: patients v professionals.

Because if the past 15 years are any guide, any solution that entails GPs being open for business longer will not be achieved without either significant cash changing hands or significant conflict.

Now is therefore time to do the right thing, having first - to borrow Churchill’s phrase - already exhausted every other possibility. Exhorting GPs has not worked. Nurse-led substitute services have not wholly filled the gap. Merely setting targets has been tried and failed. For example, the target that patients should be able to see a GP within 48 hours was clearly ‘gamed’, as shown by the mismatch between what practices were reporting to PCTs and what patients themselves experienced.

And special incentive payments to GPs have cost hundreds of millions and produced very little. Even the best GP practices seem to have given up on Saturday morning clinics.

So if persuasion, substitution, targets and cash haven’t worked, what’s left? Probably three main policy options: compulsion, capitation, or competition. Assuming he is actually going to act on the problem, it will be telling to see which if any of the three ‘Cs’ Mr Brown resorts to.

Compulsion would mean unilaterally amending GPs’ terms of service and imposing a new contract. There would clearly be an industrial relations backlash (nothwithstanding the fact that imposed contractual terms are a recurring feature of government/BMA relations since 1946). But the question is: would this disruption really be outweighed by public concerns about GP access, juxtaposed with recent stories of large GP pay rises?

Capitation might mean setting mandatory practice budgets, top-sliced from the quality and outcomes framework, that would be docked when the practice’s patients used A&E or walk-in centres. So a practice whose patients couldn’t get access to care at the practice would find itself out of pocket - the primary care equivalent of cross-charging local authorities for blocked NHS beds. An established precedent for this type of scheme operates in parts of Canada

Competition would mean practices that were not sufficiently responsive to their patients ran the real risk that a new practice would set up shop and attract its patients. This mechanism has clear advantages over the first two in that it doesn’t manifest as an act of government centralisation nor would it be accompanied by extra cash to lubricate its introduction as GPs would doubtless argue for with capitated incentives.

Indeed we are already seeing that in localities where new alternative provider medical services practices are being established by new providers offering longer surgery times, other practices very quickly follow suit to reduce the risk of patient defections.

This particular issue turns out to be an important initial case study in how Mr Brown will seek to animate NHS improvement.

He finds himself being pressurised by various staff groups to go slow on reform and tread softly on industrial relations. And this comes at exactly the time the NAO, Audit Commission and Commons health select committee are producing acidic reports criticising the government for the exact opposite failing - namely being too conciliatory to the unions on the new consultant contract, GP contract, and Agenda for Change contracts.

To govern is to choose, and by elevating the question of GP responsiveness, Mr Brown may have forced himself to choose sooner rather than later.