Arguably, general practice is the sector of the NHS that Labour's reform programme will most profoundly affect. It has been key to the creation of primary care groups, then primary care trusts, which - alongside the clinical governance initiative - represents a concerted effort to corporatise primary care.
The battle for cost constraint will be won or lost in the doctors' surgeries - as will the government's desire to manage expectations. That makes a fairly sizeable part of the government's entire health policy dependent on a semi-detached (and often disenchanted) part of the NHS.
What are the incentives for GPs to play an active part in the management of the NHS as envisaged by the government? And where might general practice be heading over the next 10 to 20 years?
The simple question, 'What's in it for us?' is not easily answered. Vague appeals to professional altruism aside, the 'incentives gap' is very likely to create real problems for all parties. It has bedevilled healthcare reform in the UK since the NHS's inception, and there is no sign that this issue will diminish in importance.
Among the more common reasons given by GP enthusiasts for active engagement in the reforms are, 'It will give us greater control over primary care development and hence resources', and 'If we don't play along, the government will find ways to make our life difficult or threaten our professional autonomy'.
The first reason constitutes a positive incentive, the second is about threat avoidance, which is effective only so long as most GPs think certain 'unpleasant' consequences would result from resisting government policy. It will be interesting to see if this in fact occurs when certain practices are shown not to be participating in audit or when PCGs overspend and demand more resources instead of approving rationalisation programmes.
Many observers think health secretary Alan Milburn is the kind of minister who is prepared to take on the recalcitrant elements within the NHS - including GPs. If he is not, or is not allowed to, the primary care foundation of the reforms may be shown to have been built on sand.
Making an example of an isolated practice is one thing, but taking on PCGs and PCTs is another matter. Besides, if overspending and poor management were such anathema to governments, how is it that so many trusts and health authorities have got away with it for years?
The answer, in part, is that for the centre the cure often looks worse than the disease. This is likely to apply just as much to issues in primary care.
There are genuine advantages to further strengthening primary care. But HA managers are already complaining that the trouble with PCGs is that they spend all their time discussing primary care issues. Never mind that they were explicitly given that remit - what HAs really want them to do is to agree to secondary care rationalisation plans and refer less. Here we enter into a complex series of incentives, which often seem to cancel each other out. For example, GPs want to see resources transferred to primary care (or perhaps, the cynic might say, to their practice accounts).
Most recognise that resources will have to be released from secondary care to do this. But this courts public controversy.
Indeed, many GPs went into the previous government's fundholding scheme in part to protect local services, and have carried the same mindset into their participation in PCGs. Everyone - ministers, the NHS Executive, HAs, trusts, PCGs, community health councils and local authorities - will want someone else to be held accountable for such decisions. Do PCGs and PCTs truly have strong enough incentives to 'step up to the mark'?
The same set of issues can be played out in relation to both prescribing and referrals. Obviously, the government - and particularly the Treasury - hopes that GPs organised through PCGs or PCTs will have a collective incentive to economise in both areas.
Some argue that this is also good medicine, although the evidence, as far as it exists, points to problems of underreferral and under-prescribing by some practitioners, as well as the opposite trends.
It is at least partly an act of faith that the introduction of protocols, backed up by National Institute for Clinical Excellence and the Commission for Health Improvement, will improve matters from a financial (if not clinical quality) standpoint.
Certainly, GPs have some incentives to economise, but the key question is whether these are more than balanced by pressures to do otherwise. Among the pressures to carry on a 'business as usual' attitude are:
patients' and relatives' expectations;
negative media publicity;
concerns that containing pressure within primary care will go 'unrewarded';
fears that overt participation in rationing will be a breach of GPs' terms of service.
It would be wise not to underestimate the potential obstacles the last of these may place, as paragraph 12 of the Red Book states: 'A doctor shall render to his patients all necessary and appropriate personal medical services of the type usually provided by general practitioners. A doctor shall order any drugs and appliances which are needed for the treatment of any patient to whom he is providing treatment.'
Paragraph 43 goes on: 'The doctor must give such treatments as he, exercising the professional judgement to be expected from a GP, considers necessary and appropriate.'
The debate over the erectile dysfunction drug Viagra is merely the first salvo in what is likely to be a long-running tension between the ethical (and seemingly legal) duty to provide effective services and the statutory duty of NHS organisations not to exceed their budgets. The recognition that, in reality, these precepts get blurred at the edges doesn't reduce the potential for conflict.
If the lack of incentives tips attitudes among GPs towards a 'carry on as before' mentality, a substantial portion of the government's health reform programme will be in serious trouble.
This is far from being an academic threat.
There remains a serious incentive deficit to get the health system in general, and clinicians in particular, to work in the way government would like them to. Whether they should operate in such a manner is a different question, albeit an important one.
Many GPs believe that the government's longterm plan is to move general practice into a salaried service and that the timescale for this will be accelerated if 'voluntary' collaboration with the reform agenda is not forthcoming.
A growing number of GPs also say they would be quite prepared to lose their independent contractor status, and these are by no means just confined to doctors working in deprived areas.
Advocates of a salaried service point to the decline in applications for GP vocational training schemes, the growing proportion of women doctors and a national preference for avoiding administrative responsibilities in favour of clinical work. Salaried service implies that someone else will undertake the burden of management of the service and its associated paperwork.
The case for a salaried service has been articulately put by Dr Julian Tudor Hart.
1 His impeccable diagnosis of the problems of establishing and maintaining decent primary care services in a deprived area summarises the problem as follows: 'With plenty of choice where to go, few want to work where caseload is double, net earnings are well below average, and future prospects seem dismal.'
Unfortunately, salaried general practice doesn't by itself change the nature of the problem. Dr Tudor Hart recognises this by calling for additional investment. One also assumes pay levels need to be higher - in part as the price to be paid for buying doctors out of their current contractor status (and their properties).
Aside from the issue of whether a salaried service will cost more, there is the crucial question once again of incentives. What is it about a salaried service that makes doctors more likely to manage their prescribing and reduce their rate of referral?
One hears GPs saying something along the lines of, 'I hope the government does make us salaried. I'd like nothing better than to work nine to five, have a nice guaranteed income and let somebody else worry about managing the practice and the finances.'
This hardly sounds like a particularly strong expression of Max Weber's Protestant work ethic. Are we to assume that the NHS, with its appalling record on the quality and rigour of consultant contracts, is going to ratchet up performance via the 'monitoring of detailed job descriptions and renewable contracts'?
In any case, the issue of the adequacy or otherwise of salaried employment as a means of obtaining high performance is far from peculiar to doctors. It applies in varying degrees to all NHS staff. Salaried general practice may be inevitable in certain areas.
If sufficiently well funded, imaginatively implemented and rigorously managed it could be the best option. For many areas, however, we are likely to see a mixed economy in primary care provision for some time yet, with salaried services the exception rather than the rule.
Those who claim there simply won't be enough GPs may be mistaken. Recruitment varies greatly from area to area, and in many places single-handed practices are being taken over by multi-partner practices which can absorb the workload.
If this turns out to be the case, both ministers and managers will have to come to terms with genuinely engaging independently minded GPs, rather than hoping that they will either simply do as they are told or disappear. They are likely to do neither.
Bob Royce is an independent consultant.
GPs are crucial to the success of the government's NHS reforms. But there are few obvious incentives for GPs to act as managers.
GPs will be under pressure to economise on prescribing and referrals but will face conflicting demands from patients.
Many GPs believe the government will rush them into a salaried service if they do not co-operate with the current reforms.
1 Tudor Hart J. Going for Gold: a new approach to primary medical care in the South Wales valleys. Socialist Health Association discussion paper, 1998.