Published: 15/01/2004, Volume II4, No. 5888 Page 19

The New Primary Care Modern, dependable, successful?

By Bernard Dowling and Caroline Glendinning Publisher: Open University Press. ISBN 0335212506£19.99

Primary care has been made the lynchpin of health provision under New Labour.But has it delivered on its promises? Margaret Mythen finds that leading academics are unconvinced

This very readable publication provides an academic romp through the development of primary care in England since 1997. Recent health policy history and much current thinking on primary care trusts has been condensed into a compact 230 pages.

The 20 contributors include doyens of health policy like professors Julian Le Grand, Steve Harrison, Justin Keen and Ray Robinson.While the publishers are aiming at health policy students, researchers, academics and policy makers, there is something in here for anyone interested in primary care.

The fact that all 13 chapters stand alone allows time-pressed health professionals and nonexecutive directors to dip in and out. All chapters are thought provoking, but do not expect many answers.

Part one explores primary care policies, concepts and contexts, with chapters on modernisation, inequalities and equity, the doctor-patient relationship and primary care reform in an international context.

Evaluation of modernisation is put in the context of a continuum of primary care development, stretching back to fundholding and tempered by the government's Third Way ideology.

A downbeat second chapter casts doubts that PCTs are more successful than the organisations they replace - a premature analysis given the lack of evidence.However, subsequent chapters seem more open-minded. The new public health function is welcomed with the proviso that the potential to reduce inequality currently lacks local direction, and as such there is a danger that health inequalities will languish at the bottom of PCT priorities.

A chunkier second part is rooted in reality. Chapters cover PCT organisation and functions, including clinical governance, information, commissioning, public health, public involvement and local partnerships. Evidence drawn on includes the national tracker survey of primary care groups and trusts carried out between 1999-2002 at the National Primary Care Research and Development Centre.

The section on clinical governance, for instance, concludes that half way through the 10-year strategy to improve quality of care, there are causes for both optimism and concern.

On the one hand, the main advantage is seen as the importance of a multi-level approach to improving the quality of care.On the other, the concept of clinical governance is seen as 'vague and nebulous'.

On commissioning, evidence suggests that the balance of power has not yet shifted significantly from secondary to primary care, and that the key may lie in a period of structural stability, so 'PCTs have both the time and resources to do what is expected of them'.

So is the new era of primary care successful? It is too soon to say. The editors evaluate the performance of PCGs and PCTs against their three core functions: to improve people's health and reduce health inequalities; to develop primary and community health services;

and to commission secondary health services.

The book also flags up possible stumbling blocks. A recurring theme is the loss of interest and engagement by local stakeholders if performance targets are not perceived to be relevant. Also, newly devolved powers are seen as 'simply the power to implement government policy rather than developing locally designed strategies'.

The editors argue that continuing the separation of purchasing and provision provides a useful evidence base.

It suggests that collaborative relationships with secondary providers, coupled with the sheer volume of the services commissioned by PCTs, are unlikely to offer the same opportunities for leverage as GP fundholding.

The editors conclude that the combination of horizontal, networked modes of governance with hierarchical and market modes of organisation may be unstable and vulnerable to renewed fragmentation and potential conflict between professional and managerial interests.

You have been warned!

Margaret Mythen is chief executive of the New Health Network.