Post-NHS plan tension: it tends to affect some primary care professionals, causing a type of tunnel vision preventing them from seeing the big health picture.
The diagnosis comes from health minister John Denham, who was addressing delegates at last week's annual NHS Alliance conference in Birmingham.
His speech to the massed ranks of clinical and non-clinical staff, gathered alongside lay and non-lay board members from primary care trusts and groups, was charming - in parts.
But it was also just waspish enough to be intriguing. Mr Denham has been minister with responsibility for primary care for two years. Still at the treat 'em mean, keep 'em keen stage.
He said he was 'surprised and disappointed' that the primary care media did not appear to seize the NHS plan to its bosom, because the massive change outlined in the plan 'could only come about with the full involvement of everyone in primary care'.
That change would 'benefit patients' and 'improve the working lives of primary care professionals'.
Yes, he realised that a lot of people thought that the plan did not promise enough GPs. And not only that, Mr Denham actually agreed with them.
The plan talks about 2,000 more GPs and 450 in training by 2004.'If anyone can show me how we can get more in the same time period, I am here to listen, 'he said.
There was a hint that there might be scope for significantly more GPs in years to come. After 2004, more GPs were clearly required, and training places would be expanded to meet this need, he emphasised.
The NHS Alliance is disappointed by what it sees as an undervaluing of heath services outside hospitals. Grievances include 'no primary care organisations on the modernisation board' and no taskforce for primary care.
So, surely it would be delighted with the minister's announcement of its very own workforce review, 'looking at what needs to be done so that the workforce for primary care is fully planned at a local and national level' over the next 15 years or so.
The review would look at both the medical and non-medical workforce and 'go well beyond the practice base'.
Not only that, but the alliance's chair, Dr Michael Dixon, was going to be one of the members of the external reference group.
The delegates seemed to react like women whose life partners had just presented them with a vacuum cleaner for a birthday present.
The minister said he had asked primary care groups earlier this year to come forward and contact the Department of Health with examples if they felt they were being coerced into becoming primary care trusts - and was 'relieved that no complaints were forthcoming'.
But when this was put to the electronic voting test at the conference, 79 per cent of delegates disagreed that there had been an absence of pressure.
Dr Dixon seemed to be reacting towards the government like a spurned lover.Nobody could doubt that the alliance's document Implementing the Vision published in March had a 'major impact' on the NHS plan, he said.
But 'nowhere, nowhere in the plan is there any real focus, any real attention to primary care', he complained.
Given that the creation of PCGs and PCTs was the 'most innovative, the most exciting and by far the most significant change that the government has made to the NHS, why put just the usual suspects on the modernisation board?'he asked.
Yes, it was true that 'GPs are represented by the Royal College of General Practitioners, nurses by the royal college and health authorities and management by the NHS Confederation'.
He said he knew that many of the new PCTs had joined the confederation, and while having 'no criticism of that', he said that trusts which relied on any other organisation to represent them and which were not part of the alliance 'were disenfranchising some groups within their own organisation'.
'Certainly the confederation does not - and never could - represent clinicians, 'he added.
As far as the alliance is concerned, 'the door is opening - but it is not wide enough and it is not opening fast enough'.
While waiting for that 'gilt-edged invitation' to the modernisation ball, the organisation would use the NHS plan to 'build a vision of primary care that is fairer, stronger and more committed to the patient than ever', promised Dr Dixon.
As a follow-on to Implementing the Vision, he announced that the alliance would be starting to draw up a proposal for a 'people's health service in primary care'. It would be an action plan embodying the spirit of the plan, 'but allowing primary care to take the initiative and to ensure proper ownership and enthusiasm at grassroots level'.
Speaking from down there at the roots, chair of Harrow East and Kingsbury PCG Dr Chaand Nagpaul talked of a 'tidal wave of change over the last 18 months'.
There were 'feelings of being overwhelmed', and the 'need for stable organisations'- hence his own group's decision not to go for trust status before April 2002, he said.
Morale was 'variable', with large numbers of professionals feeling overloaded. A number of issues remained to be cracked, including when to 'refer up'poor performance and concerns about PCTs 'becoming too big'.
Chief executive of Peterborough South primary care trust Dr Lise Llewellyn said becoming a trust 'provided new opportunities because of the size of organisation we are'.
But quality should not be ignored, she stressed.
'It's about ensuring that when a patient goes into practice A or practice B they get the same quality of service'.
Education and training had to be put into the delivery of those quality services, she added. Her trust encouraged practices to shut for half days in order to share their successes and 'near misses'.
Chair of the National Institute for Clinical Excellence Michael Rawlins said the clinical guidelines it was issuing would lead towards comprehensive coverage of the main causes of mortality and morbidity. Although they would be 'very draconian', he said there would be 20 per cent of patients 'where guidelines would not be applicable because of personal circumstances'.
The guidelines would not replace 'clinicians' expertise, judgement and skill', he told delegates.
In cases of litigation, his feeling was that if people could 'say they used the guidelines' that would be a reasonable test.
He added: 'If you decided to depart from NICE guidelines you should make a contemporaneous note - not two years later when the writ arrives.'
He said he was 'surprised' its decisions so far had not been the subject of a judicial review, given that European human rights act law had been adopted in the UK this month.
Before the chair of the Commission for Health Improvement, Dame Deirdre Hine, spoke, the delegates seemed nervous following news that her review would be starting to make its first forays into primary care.
But Dame Deirdre appeared to reassure them.
'The best people are most often apprehensive, ' she said soothingly. Assessments would be peer reviews and the first four years would be successful if primary care came to regard them 'more as an opportunity than a threat'.
Straight from the heart: primary care's role Professor Sir George Alberti, co-chair of the national service framework for coronary heart disease and president of the Royal College of Physicians, is well aware of the importance of primary care to meeting the targets on heart disease.
Factors limiting the success of the framework were staffing and limited funds, he said, questioning whether the funds mentioned in the NHS plan were enough.
'We do hope the money will be made available as well as being there', he offered in his enigmatic way.
He told HSJ that as far as the framework for coronary heart disease was concerned the formation of primary care groups and trusts had 'made our jobs easier'.
Did he believe there was a clear role for primary care in future?
'I see a strong future for care outside hospitals. There will be some pretty big changes in the way primary care and intermediate care functions.'
He sees combined groups of consultants, GP specialists and ancillary staff being 'very powerful'.
For the next 10 years there should be 'no problems' for non-specialist GPs, 'but in 25 years there will be a very different pattern of care'.