The personal medical services experiment may prove the most influential corner of the whole new NHS. Why is the second wave of pilots - recently announced - so large, and what might they mean for the rest of the NHS?
The origins of personal medical services lie with the last government. The Choice and Opportunity white paper, published in winter 1996, was a direct consequence of the Conservatives' 'listening exercise' earlier that year, and was intended to free some of the mechanics of primary care so that options the exercise raised could be tested in relative safety.
It marked a genuine change in government policy: for the first time during that administration, it looked as if real experiments could be conducted in the NHS - a tacit acknowledgement that alternatives to political dogma (as demonstrated with the introduction of fundholding in 1990) did exist when creating change in the public sector.
From the white paper emerged the choice and opportunity pilots in which different models of primary care contracts and delivery systems set out to test salary options, alternatives to the 'Red Book' and so on. The white paper became law just before the 1997 general election, with some cross-party support, but the change of government occurred before any of the experiments could be started.
After the election, choice and opportunity pilots became known as Primary Care Act pilots, with a starting date of 1 April 1998. But The New NHS white paper distracted attention from Primary Care Act pilots as the service grappled with the meaning of primary care groups. Even so, 88 pilot sites were formally launched in the first wave.
Most concerned different models of GP contract, with a salaried option offering some GPs the chance of being employed by a community trust, or hired on a sessional basis by nurse practitioners. In some deprived areas, imaginative health authorities used the pilots to bring more money to their districts through the general medical services budget. Early moves towards GMS equalisation across the country were demonstrating wide variations, often showing glaring examples of the inverse care rule, with relatively less spending in disadvantaged areas where it was needed most.
Primary Care Act pilots were seen as a vestige of the previous administration, in many ways an appealing perception since it kept the spotlight away from the experiment. By autumn 1998, with shadow PCGs being formed, it was doubtful whether a second wave would be allowed, and misgivings were expressed about how the pilots would impinge on the concept of the PCG.
At this stage, the pilots were renamed again as personal medical services sites, and their expanded cousins - the PMS-plus sites - were introduced to include hospital and community health services in addition to general practice types of service.
Most personal medical services sites encompassed a single practice, either working on its own or under the auspices of a community trust. How did that fit with the new corporacy demanded of PCGs, which had to include all practices in their area?
Individual personal medical services pilots might find different ways of doing things, raising the spectre of professional inequity so recently quashed with the demise of fundholding. Giving responsibility for the sites to the PCG itself only devolved the problem, and emphasised it.
What was the purpose of introducing internal variation when the service at large was heading for more consistency, not just in standards, but delivery? The personal medical services idea began to feel like an idiosyncratic worm inside the corporate apple, run by mavericks - usually GPs - who wanted nothing to do with the emerging models of communitarianism and egalitarianism.
But a separate thread was beginning to develop which we are only now starting to weave into the main fabric of the NHS. PCGs were just the beginning of the story, and the concept of the primary care trust was so new as to be barely understood.
PCTs seem odd animals: why bother to become independent from your HA if it is co-ordinating all your activities successfully, and listening to your advice about commissioning decisions? Who wants to go to level 4 if it means taking on the corporate risks of a community trust, including capital assets, staff disciplinary machinery and work rotas?
A separate debate arises here about how the service is picking up the baton of PCTs before the politicians are sure they want to let it go. It involves individual clinicians' and managers' ambitions to determine their own futures.
PCTs are running ahead of legislation. But perhaps it may not be required at all if personal medical services mechanisms can be used. Personal medical services offers the possibility of new contractual arrangements, outside the NHS's normal procedures. GPs may be salaried, terms and conditions may be varied for all staff and many other NHS rules may be flouted.
Imagine a whole PCG taking on personal medical services and working with its local trust on a seamless model of care delivery in which the boundaries between general practice and community care dissolve. Lo and behold, a PCT emerges - without the need for laws and regulations. Have you got a whole PCG personal medical services pilot in your area? Can you invent one in time for the next wave? And if you can, are you creating a brave new paradigm for the future or a genetically modified monster?
Jonathan Shapiro is a senior fellow at Birmingham University's health services management centre.
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