Doctors have mixed feelings about the progress of personal medical services contracts, and the government is cagey about whether its targets are being met. Alison Moore assesses the ups and downs of the schemes

Published: 04/04/2002, Volume II2, No. 5799 Page 12 13

Governments like targets - as long as they are met. So it is no surprise that there has been a deafening silence surrounding the pledge to have 30 per cent of GPs working in personal medical services pilots by 1 April - yes, three days ago.

Despite strenuous efforts to persuade GPs to break with the tradition of self-employment to become salaried like their hospital colleagues, perhaps only 20 per cent will make the leap. All the Department of Health will say at this stage is that it will not know how close it is to the target until the end of April.

But four years after the first wave of pilots went live, is this new form of providing medical care to areas with the greatest GP shortages bringing the changes it is meant to?

Dr Richard Lewis, a visiting fellow at the King's Fund who has carried out extensive research on PMS, says the scheme has met some objectives, but not all. It has improved services in some deprived areas where conventional primary care under the traditional general medical services contract was under-performing, simply because it did not have the resources to meet demand.

PMS has also allowed resources to reach services dealing with those who are hard to reach or who traditional GP services find difficult to accommodate - such as homeless people or asylum seekers.

'PMS has trod boldly where GMS feared to tread, ' says Dr Lewis. But many of these schemes have been run by community trusts, which find it hard to be quick and responsive to local needs.

GP Dr Ron Singer from the NHS Alliance believes there is no clear evidence that PMS has improved healthcare despite all the money put into it. 'Overall, PMS projects have probably been better funded than equivalent GMS practices, making direct comparison difficult.'Dr Lewis agrees the two seem 'broadly equivalent'.

That may be a disappointment to those who thought that freeing doctors from some of the shackles of running a small business would transform healthcare.

Of course, many of those shackles have remained. British Medical Association GPs committee member - and third-wave PMS GP - Dr Julian Neal says PMSplus schemes have failed to thrive, because resources have not been released to general practice to take on work previously done in the secondary sector.

But Dr Mo Dewji, head of the national PMS development team, says: 'PMS has to be seen as a tool to enable improved practice rather than just something you do for a target.'

He believes PMS has started a broader cultural shift: 'PMS has given us the opportunity to review primary care - you have to look at the quality you offer, and PMS has started that. The cultural barrier has been moved significantly.'

Many GPs may be waiting for the outcome of negotiations on a new GMS contract before deciding which way to jump. The new contract is expected to offer a menu of options from which GPs can pick. It may undermine PMS.

Both Dr Neal and Dr Singer say their practices will reconsider their futures when they have seen the new contract.

But Dr Dewji - who also works part-time as a GP - points out the contract is likely to offer elements which are locally based and practice-based - two essential components of PMS - but will not offer a totally locally based contract, as PMS does.

'GMS and PMS are likely to run hand in hand, 'he says, pointing out that there is already great interest in the wave of pilots, which go live in October. 'I would not want a patient to be able to say That is a PMS practice, That is a GMS one. I want them to say, 'I go to my GP and get a great service'.'

Many GPs do still have reservations about PMS - for example, about how their pension would be calculated and whether they would be able to return to GMS if their PMS scheme did not work out.

Currently, all the schemes are running as pilots and GPs have been protected: once the GMS contract is finalised, the government is expected to offer some pilots the opportunity to become permanent. Some GPs working in PMS feel the scheme is becoming too centralised and is losing the local-needs focus which attracted them - the third wave was much more tightly controlled than the earlier ones.Concern that the core PMS contract, determined nationally, was becoming too prescriptive was voiced at a number of 'listening events' held by the DoH last year, and new guidelines have been issued.

But it may be harder to reassure GPs who feel they are swapping what is effectively an unlimited budget for one which is cashlimited.Cash may be even tighter, as what was a relatively ad hoc method of determining funding for PMS schemes is replaced by a more calculated one. And primary care trusts, which will hold PMS contracts, may be looking for tangible results. l Steering a course: nurse-led pilots One of the original ideas behind PMS was to encourage different methods of providing care, especially for disadvantaged and vulnerable groups.One experiment has been nurse-led care.

Nurse practitioner Lance Gardner took over a vacant single-handed GP's practice in 1998 and bought in medical cover.When Mr Gardner left last year, the Salford practice merged with another local one.Though there is still substantial nurse involvement, it is no longer nurse-led .

Mr Gardner now thinks pilots should be team-led, but he is still a supporter of PMS and argues that the Salford experiment showed that there was more than one way of delivering care in the inner cities.

Dr Lewis says some have had success in working with the local medical community, including getting consultants to accept direct referral from nurses.But others have found it hard to get agreement over the differing roles of doctors and nurses.

The way forward? PCT-wide contracts Gedling primary care trust, just outside Nottingham, is looking at a PCT-wide PMS bid which would access growth money to develop better integrated services. It would work closely with social services to improve services for older people and would also use existing GPs with special interests in areas such as mental health and substance abuse to develop these services, working with nurse practitioners.

Jeff Anderson, the PCT's PMS project manager, hopes that by the end of the summer the area's 15 practices will be able to see the advantages of PMS.But he admits that the scheme would be hard to run if a large proportion of practices decided not to join.Even so, the process has been beneficial: 'If we stopped PMS work now, we'd still have made great strides in terms of our relationship with practices, with other agencies and in the developmental work we are doing, 'he says.