OPEN SPACE: GPs need to hang on to a certain amount of autonomy to provide a personalised service to their patients in the age of the primary care trust and patient protocols, argues Dr Andrew Spooner

General practitioners are unhappy and reporting low morale. Among their complaints are increased paperwork and a diminished sense of involvement in the change process.

Becoming a GP appeals to a self-selected group:

they relish the independence to make an impact on people's health by running an efficient, welcoming practice. They want to provide optimum individualised patient care and form rewarding, personal relationships with patients.

Patients often have multiple illnesses that do not fit well with protocols. GPs expect to work hard, for long hours. This is balanced by the reward of helping patients, a varied work pattern and the autonomy to alter details of their practice.

But their expectations have been steadily eroded.

The NHS plan calls for fast and convenient healthcare, delivered to a consistently high standard. In some places it promises local autonomy to GPs; in others it calls for protocolbased care to take hold throughout the NHS.

GPs are unhappy with the reduction in clinical freedom and subsequent scrutiny inherent in the imposition of clinical pathways. They fear it will lead to the loss of much they thought was important.

Responsibility for implementing this will rest with managers, who are likely to have their pay and even the continuation of their jobs linked to achieving the government's agenda. They will be caught between potentially conflicting forces.

Managers could use various strategies to achieve a change of infrastructure and staffing. At the extremes, primary care groups might use their power over the allocation of finance to micromanage skill-mix, staff pay levels and who will be employed. They could dictate the business plan and specify computer systems across an area to facilitate the external audit of practices. Overall this reduces practices' ability to plan, and concentrates decisionmaking at the PCG or primary care trust level.

Conversely they could use the main headings of the national service frameworks and National Institute for Clinical Excellence guidance to macromanage practices to plan as a unit, using the skills of all staff to adapt national initiatives to their needs.

There can be difficulties with clinical standards if a specific action is required in response to a symptom.

For example, the cancer guidelines require referral to secondary care if rectal bleeding is found. But this could lead to inappropriate referrals. Referral for carcinoma is good, but instant referral to a cancer clinic with obvious piles or colitis is not.

Some GPs may feel confident to ignore protocols, but if something goes wrong there is the multiple jeopardy of the complaints and discipline systems. \ At present these clinical targets apply to a small part of the workload, but the NHS plan implies that they are to increase dramatically.

Managers should aim to increase the number of GPs involved in change and reduce the number who are disillusioned or fighting it.

One example of high-quality care for multiple chronic diseases that fits with the aspirations of GPs has occurred in East Kent health authority. The initiative, known as the primary care clinical effectiveness project, gave clear statements of the standards to be achieved. Additional resources were made available to enable practices to make their own internal management changes, but the clinical methods were left to practitioners.

The standards were chosen with care and could withstand challenge. The GPs had the autonomy, professional pride and additional finance to improve patient care. Running their own businesses allowed them to make local changes that were different in each practice.

The GPs delegated, and worked within functioning teams. The process changed their views, and they came to believe that uniform implementation of the interventions could improve patient care. Guidelines were used, but they were created and adapted in each practice, rather than imposed.Morale improved as a result.

The scheme was prescriptive in some ways, but it worked with GPs' desire to own and develop change at the practice level - which is quite different from imposing a clinical pathway.

In the US, micro-managing doctors has been reported to increase burn-out and reduce commitment. The morale of GPs will suffer if their autonomy is threatened.