'While other parts of the public sector have learned to work with a mixed economy, the NHS still flinches at the idea of private involvement'

A month after taking office, Gordon Brown's government has taken its first steps towards delivering his pledge to improve access to healthcare.

The springboard was the publication of the biggest ever patient survey - involving over 2 million people - examining access to GP services (see 'Johnson wants competition to prop up poor GP access').

The figures, which show more than three-quarters of patients are satisfied with their GP's performance in service areas including opening hours and making appointments by phone, mask disturbing local variations.

The link between access and affluence is starkly revealed. Barking and Dagenham primary care trust, for example, has 43 GPs per 100,000 population, less than half the number serving Northumberland.

Ethnic minority patients also tend to suffer an inferior experience. Bangladeshi respondents are a fifth less satisfied than white residents.

Compulsion, capitation, competition

When Mr Brown used his Labour leadership campaign to promise better access to primary care, HSJ columnist Simon Stevens pointed out the government had three options for delivering it (opinion, page 19, 7 June): compulsion, capitation charges if patients were forced to use services such as accident and emergency, or competition.

Health secretary Alan Johnson has now revealed that his weapon of choice is competition. Responding to the survey he made clear that PCTs in areas of poor access would be expected to produce local action plans to secure improvements, and will be expected to invite competitors to offer services.

The furore last year when a private firm was invited to run a surgery in Derbyshire shows the difficult territory Mr Johnson is now moving into. While other parts of the public sector have learned to embrace, or at least work with, a mixed economy of public and private provision, in the NHS, a large proportion of staff and many patients still flinch at the idea of private involvement in services.

But endemic weakness in GP provision in deprived areas means ministers have a choice of either reneging on Mr Brown's first promise on health or being willing to challenge existing orthodoxy.