the columnist

Published: 08/01/2004, Volume II4, No. 5886 Page 19

Dr Tom Coffey is a south London GP and professional executive committee chair, Wandsworth PCT

The work of patient and public involvement czar Harry Cayton and his cadre of patient choice exponents has surprised many GPs.Most believed that the initiative would have its greatest impact on elective surgical care. But the recent consultation has produced a much greater focus on primary care.

Offering patients a choice of five sites of referral when they see their GP will put the doctor in the driving seat as to where patients seek secondary care. It is likely that as we inform patients of the choices, so referral rates will increase.All treatments will be costed at an agreed tariff and PCTs will not be able to reduce the cost of care by shifting patients to a cheaper provider. The only way to implement cost containment will be on the demand side.

A number of PCTs have already incentivised their practices to manage their referrals proactively. It could be possible for practices, or groups of practices, to be given a budget which covered their historical spending on all but the most complex and rare cases.A practice will be free to develop in-house services and outreach clinics and could use an underspend to invest in staff or service development.

Thus at the point of referral, patients could be offered the option of having their care close to home within primary care. This is not dissimilar to the model operated by Californiabased Kaiser Permanente. It mixes financial incentives to primary care, clinicians with an investment in the system and a genuine movement of care from the hospital to the community setting.

The patient choice consultation document indicates that there may be movement towards allowing private providers into the primary care provision, both in-hours and out of hours.Our PCT has recently used a private company, as an interim measure, to run a twoperson practice where both GPs resigned. I am sure there will be a number of companies which would relish taking over a practice list or offering a range of enhanced services to a PCT. The government would find this especially attractive in areas where it is hard to recruit GPs and list sizes are often over 3,000 patients per doctor.

A more controversial area for GPs is the indication that patients will be allowed to register with a GP both at their place of work and where they live. The continuity of care and consistent approach to medical and social problems is the cornerstone of good general practice. Two GPs per patient may fragment a service and potentially double the cost without any proven benefit.

The NHS already has a system whereby patients can register either as a temporary patient or for immediate necessary treatment from a GP near their work. It may be more sensible to expand and refine this option as opposed to developing a contentious and expensive one.

Overall, the impact of patient choice on general practice will be invigorating. The development of practice-based budgets for all (unlike in the days of fundholding), with the movement of secondary care into the community, will bring real meaning to a primary care-led NHS. General practices will then appear much more like foundation trusts, with the added benefit of being able to borrow finance outside the limits of the NHS limits of expenditure.