Published: 27/05/2004, Volume II4, No. 5907 Page 16 17

The government hopes 'constructive discomfort' in primary care will be good news for patients.But what will it mean for the new breed of entrepreneurial clinicians and managers?

As NHS purchasers and providers acclimatise to the new GP contract, it is clear that further major reforms are being devised in English primary care. The focus of these changes is the use of market incentives to ensure 'constructive discomfort', which the government believes will encourage the provision of better services for patients (see the recent article by the prime minister's special policy adviser on health Simon Stevens in Health Affairs Journal www. healthaffairs. org).

Since April, GP practices are contracted to deliver varying levels of care: essential, additional and enhanced. The basic contract is for 8.30am-6.30pm each weekday. GPs can decide not to do out-of-hours work and forego£6,000 per year. In this case, primary care trusts are obliged to provide out-of-hours care.

The new GP contract creates a sharp entrepreneurial environment. Its quality framework rewards behaviours that are generally evidence based.

It consists of 10 clinical areas, a set of organisational measures and rewards associated with quality, access and patient experience. The contract provides incentives through a points system. Each point awarded - up to a total of 1,050 - is worth£70 in 2004-05, rising to£120 in 2005-06.

In the clinical section of this quality framework there are 550 points related to areas such as hypertension control, coronary heart disease, diabetes and asthma. In hypertension, the practice has to have a register of established patients with high blood pressure and this register must record both the smoking status of the patient and whether they have been offered cessation advice. There are also points for the measurement of blood pressure and the maintenance of BP levels below 150/90.

Evidence that fee-for-service payments increase activity levels can be seen in the impact of the 1990 GP contract.Here fee payments increased the provision of new types of care, and target payments drove up vaccination, immunisation and cytology activity rates. The new contract puts up to 30 per cent of practice income at risk. Radical changes in behaviour, organisation and activity are inevitable.

The government wants to offer incentives to increase activity levels and conformity with national quality standards. This may lead to changes in the ways care is delivered. Some practices are already reviewing the skill mix of their team.Many of the clinical quality targets can be delivered efficiently by nurse practitioners, particularly if they have prescribing powers.

Practice managers are therefore considering the replacement of GPs with nurses. If this is developed systematically, the GP 'shortage' could be translated into a 'surplus' as patients are triaged between nurses and doctors, and doctors manage list sizes perhaps double those of today - 3,000 patients per GP. But can nurses deliver a wide range of services at lower cost without prejudicing patient health?

Nurse substitution will be constrained by the supply of nurses and the time and money needed to upgrade their skills. It may be encouraged by the development of earnings differentials that will challenge those staffing hospitals.

The law requires that a GP practice need only have one GP, and this practitioner may be part time. It is therefore possible to envisage practices that provide care for thousands of patients and are almost completely nurse staffed.An really entrepreneurial GP could establish a chain of practices with nurses providing much of the care.

The government has decided to allow practices to buy and sell their goodwill - the sum that can be charged for the 'custom' of patients on top of tangible assets.

This is a nice potential bonus for practitioners.However, it is also an incentive for 'corporatisation', or the sale of practices to commercial entities. In the dental market, firms such as Oasis have bought up practices, with dentists becoming employees rather than employers. Selling GP goodwill can bring retirement or investment opportunities to GPs as well as relieving them of their management responsibilities.

The entities that emerge may be profit making or non-profit making. They may contract with primary care trusts to deliver care and the new GP contract will be part of that relationship, but PCTs may also wish to develop wider contractual arrangements.

For example, it is obvious that early detection of heavy users of hospital facilities is possible and that this information can be used to create care packages that monitor and sustain patients in primary care settings. The financial savings to PCTs by reducing hospital admissions are considerable.

US firms such as Evercare have developed these types of policies and are piloting them in the English NHS. The obvious next step is to contract with GP practices to provide monitoring and community support.

When these trends are combined with corporatisation, we may see the development of 'chains' of GP practices. These would be branded and offer a form of quality control. GP practices would develop into larger organisations, cover bigger populations and exploit common systems, as a result reaping the consequent economies of scale nationally. The corner-shop ethos of general practice may be translated to a Tesco Metro approach, with enhanced control of costs and quality in the delivery of patient care.

An essential part of any development of this type would be quality control.Healthcare in the future will consist of relatively rare and short periods of hospitalisation and the management of chronic-disease within integrated packages of care that combines specialist and generalist monitoring and interventions; what some call disease management.

This scenario poses two challenges: first, ensuring the packages of care and their practice guidelines are developed on the basis of cost-effectiveness, and second ensuring that patient health-related quality of life is monitored and an integral part of quality control.

The National Institute for Clinical Excellence bases much of its clinical guidance on clinical evidence, largely ignoring costeffectiveness data. The deficit in NICE's practices needs rectifying to support primary care contracting.

The quality of primary care practices and the work of secondary providers can best be monitored with a health-related quality of life measure. Generic measures, such as SF36 (www. sf36. com) and EuroQol (www. euroqol. org) which can be used across a range of conditions.

If these were routinely used for every contact with practitioners, the functional status of patients could be better managed, as could the performance of healthcare teams and organisations.

PCTs may monitor and manage providers, both in primary and secondary care, to ensure they have such quality assurance processes in place.

An alternative to PCT purchasing is the devolution of budgets to practices, and their merging with hospitals to provide integrated packages of patient care. In the US, they call this system of integrated finance and provision health maintenance organisations. The British equivalent, GP or total fundholding, in retrospect appears to have reduced hospital use significantly.

1The benefits of all these innovations may be considerable, but the risks are obvious as markets can be destructive as well as constructive.

Prime minister Tony Blair's desire to see the NHS acting smarter has now evolved into the use of markets as a means of ensuring 'constructive discomfort' for purchasers and providers. Life in the English NHS will be very interesting for the entrepreneur class of managers and clinicians. l Professor Alan Maynard is director of the health policy group at York University and chair of the York health services trust.


1.Dusheiko M, Gravelle H, Jacobs R, Smith P.The effect of budgets on doctors'behaviour: evidence from a natural experiment.Technical Paper 26.York University centre for health economics.

www. york. ac. uk/inst/che/tech. htm