Published: 03/02/2005, Volume II4, No. 5941 Page 17

As the year progresses, our enthusiasm for developing management of long-term conditions, unlike our New Year's resolutions, does not wane - nor should it.

The NHS is good at crisis management, but quality care for patients with chronic disease is more than crisis management.

Patients should receive a rapid response in an emergency, but should also expect to have greater control of their illness through being an active partner in the ongoing management of their condition.

I have now stopped counting the tales from family, colleagues or friends of instances where one immediate crisis was dealt with excellently but the patient was left with the nagging fear of, 'so what happens next time?' Although academics continue to argue about the emphasis and role of case management, the general direction must be right. However the success of chronic-disease management not only depends on the new types of services but also the building blocks of generic primary care.

Locally, major capital developments predicated on a significant shift of care into the community are progressing fast.

This shift is backed by patients, but a common cry from all parts of the NHS is how can primary care do more when it is often so hard to fill GP posts?

Part of this response is a defensive reaction to change, but there is an underlying concern about the ability and capacity of primary care to expand to meet these new challenges.

The new general medical services contract (not yet a year old) has a number of aspects that encourage good chronic-disease management.

The quality and outcomes framework supports and rewards consistent planned disease management and the enhanced services workstream allows and expects investment in primary care to support the movement of care into the community.

More controversial, and untested, is the ability of primary care trusts to contract for primary care in new ways. New GMS practices can now be supplemented by personal medical services practices, PCTprovided services and, finally, alternative providers of medical services (APMS). It is APMS that is attracting increasing attention and is dividing opinion.

The rhetoric tells us APMS is a flexible contracting tool that allows PCTs to bring in the right type of service to meet local needs. So in a deprived area with GP recruitment issues, the services may be provided by a more flexible-style practice involving physicians' assistants, social carers and voluntary sector support. In a young population the PCT could let a contract to provide sexual health services, including traditional genito-urinary medicine hospital services and health promotion.

APMS can deliver focused primary care or joined-up chronic-disease management. It sounds like PMS, so what is the difference? Well, APMS contracts do not have to involve an independent contractor, usually a GP practice or co-operative, from the PCT's approved list.

The argument goes that if the existing pool of medical practitioners on our lists was large enough, PMS would have solved the problems of capacity. APMS allows us to look outside the traditional pool to private providers.

Pharmaceutical companies, for example, seem to have untapped reservoirs of clinical staff that can be drafted in to solve the problems created by the GP recruitment problem.

At a recent speed-dating event (business, honest) of potential providers and commissioners it was extraordinary to see the range of problems and solutions on offer.

One size definitely did not fit all.

Independent sector providers were certainly convinced about the need to engage with local PCTs to identify precise problems and solutions, echoing the painful reflections of independent providers in secondary care.

The challenge is how to improve the communication about the range of issues that need to be tackled and to maintain ongoing contact between the local NHS and providers.

In commissioning through this route, PCTs will have to become much sharper at defining the type of primary care needed, and will need to supplement the new GMS contract in many areas.

There is real potential for APMS to address the capacity issues in the community but only if we remember that APMS was introduced because it could provide a local solution to a local problem.

The recent HSJ independent treatment centre survey (news, pages 5-9, 20 January) showed that if handled badly national implementation can cause huge frustration and anger.

Indeed the anger is so strong that some board members are prepared to put their jobs on the line in raising objections. The lack of local flexibility in this area is making it hard for NHS leaders, used to explaining numerous changes, to justify the benefits of an approach which seems to require local NHS services to be reduced precisely at a time when staff were expecting investment.

At the speed-dating event, health minister John Hutton stated that there would be no national contract or procurement process planned for APMS.

He also said that there would be no national target, unlike the goal set for the secondary care's use of independent sector. Huge sigh of relief around the room.

APMS allows PCTs to be flexible in how they deal with local access issues.

Targets for implementation would only turn the introduction of a APMS services into, at best, another tick-box exercise and at worst a battle ground where the real benefits to the local community would be lost.

Lise Llewellyn is chief executive of Brent primary care trust.