Published: 06/01/2005, Volume II5, No. 5937 Page 29

Two years ago, when he was still BMJ editor, Richard Smith asked: 'What is it that doctors offer that other professionals cannot?' 'Diagnosis, diagnosis, diagnosis, ' responded chief medical officer Professor Sir Liam Donaldson.

Thirteen years ago, working as a single-handed GP, I would have disagreed. However, I now acknowledge that my management skills are deficient, my book-keeping chaotic and I am less rigorous than others in following protocols for management of long-term disease.

In common with many GPs, diagnosis is what I do best.

There are now strong arguments in favour of nurses taking a lead role in managing long-term conditions and for pharmacists to take on medicines management.

However, suggesting that primary care professionals are a homogenous group that should 'trade down' to the cheapest option is inappropriate.

For example, some PCTs are seeking to use nurses in preference to GPs across areas such as assessment and treatment without considering the evidence for such change.

Nowadays the issue is not who should do what, but how greater capacity, improved quality and enhanced choice can be achieved.

Many practices faced with improving the management of high blood pressure, elevated cholesterol or diabetes are moving away from traditional approaches.

The new general medical services and personal medical services contracts have encouraged such innovation, with nurses, pharmacists, healthcare assistants and even expert patients taking on more central roles. GPs are left to maintain an overview.

Primary care trust commissioners are also required to recognise opportunities for healthy partnerships with a variety of other agencies. Strong public sector partnerships have already been developed with local authorities and the time is now ripe to recognise the complementary strengths of the commercial sector.

Thus, while PCTs must be clear about their public sector responsibilities and communities' needs, they can now harness publicprivate partnerships to deliver some of their key objectives.

A commercial company would probably wish to target its activities on areas where it could perform better or more cost-effectively than the NHS. Whereas the public sector may be best placed to address the needs of the poor and vulnerable, commercial companies have other skills. Within primary care they have brought in new skills in management, IT, planning and disease management. The commercial sector also has more expertise in establishing a consumer focus.

Recent policy changes have emphasised the need for greater consideration of skill-mix in primary care using a plurality of providers.

PCTs are now permitted to commission primary care services from the voluntary sector, not-forprofit organisations and NHS bodies, in addition to commercial providers.

Recent changes to the regulations governing the sale of goodwill (that is, provision of out-of-hours, additional or enhanced services, or non-medical business interests), together with alterations in NHS funding mechanisms, may further encourage independent sector service provision in primary care.

With patient choice as the central focus of the NHS, private, public and professional boundaries will inevitably become more blurred.

However, certain skills should, by virtue of the distinct nature of medical professional training, stay within the remit of the family doctor.

I, for one, would not give up diagnostics without a fight!

Dr Nick Summerton is a GP and PCT medical director.