HILARY THOMAS ON CLINCAL MANAGEMENT

The changing nature of the relationship between doctors and patients was explored in a recent discussion paper by the King's Fund.

On Being a Doctor: redefining medical professionalism for better patient care looked at how the compact between doctors, patients and government has changed in recent years.

It has been a steady progression, accelerated intermittently by events such as Bristol, Alder Hey and Shipman. The paper charges the medical profession with leading the translation of this compact into everyday practice. So how can we make this a reality?

The government's desire to respond to patient expectations of more customer-focused healthcare has been hijacked by initiatives like choose and book. But the delays in implementing choose and book and the ensuing media debate have already undermined it. GPs do not believe that the required investment of their time and resources will be matched by the benefit to patients.

Knowing the date and time you will see a specialist when you leave your GP's surgery can only be an improvement. The danger lies in the trade-off. A shorter wait for an inferior service, especially if it has to be repeated or rectified later, serves neither the patient or the taxpayer.

Given the lack of robust data about many services and the difficulties in making comparisons, it is hard to see how a smart GP could advise on more than one or two options. Is the patient to be left to the mercy of public relations?

Then there is the issue of equity.

The worried well can already exercise choice, but what of the deprived sick for whom travel to one of five providers is not feasible?

At acute trusts it will create a sense of loss of control for many consultants and there is a danger that early glitches in the system will be greeted with detachment, making it more difficult to implement.

In contrast with choose and book, practice or locality-based commissioning, where the government seems reluctant to be prescriptive, does offer the hope of greater clinical engagement. GPs with fond memories of fundholding and primary care groups are already devising plans to develop better quality services in-house and commission more innovative models of care from trusts.

Forward-thinking trusts can offer greater vertical integration of services with the possibility of better chronic-disease management and more sophisticated demand management.

This may be fertile ground for the new medical professionalism - an opportunity for secondary and primary care to work with patients to devise services with characteristics important to them, and the freedom to refine and grow outside the vagaries of government or media scrutiny.

But not everyone is convinced that doctors have experienced a visceral conversion to the new medical professionalism.

Speaking at the King's Fund launch of the report, National Consumer Council chair Dame Deirdre Hutton said there was no sense from the medical profession that where they are going 'might be a really good place to be'.

Whether this is fair comment or not, the doctor-patient relationship offers a unique opportunity to engage patients in service development in a way that government alone cannot. We should cherish this relationship and use it to set up a meaningful dialogue in educating patients to set the agenda.

Professor Hilary Thomas is medical director of Royal Surrey County Hospital trust and professor of oncology at Surrey University.