Primary care groups were the focus of GPs' anger at the local medical committees conference. Mark Gould reports
Mike Farrar, head of primary care at the Department of Health, looked terribly glum. Sitting high up in the gods as the British Medical Association's local medical committees conference progressed, he had a face like thunder.
GPs on the podium far below bellowed threats about industrial action, withdrawal of services and other unpleasantness about primary care groups.
In the end, the sound and fury signified not much more than that. Angry motions full of bluster and threats were rejected.
The bow-ties from the shires, each armed with dayglo red voting cards had their thunder stolen by health minister Alan Milburn, who nine days earlier had conceded a raft of demands over power, finance and autonomy.
Although, as several speakers, including general medical services committee chair John Chisholm, conceded, much hangs on Treasury generosity after the comprehensive spending review.
In his state-of-the-nation speech to conference, a suitably pleased-looking Dr Chisholm summed up what Mr Milburn had agreed: 'If locally you wish to drive the agenda of primary care, you can take charge.
'If locally you fear being blamed for service deficiencies and rationing without the public understanding where the true blame lies, you have the right to stay in a minority on that board. The choice is yours.'
But that did not mean the 500-odd GPs at the conference did not want more reassurance on their roles in PCGs.
They still wanted gilt-edged promises or more work on (among other things): finance, autonomy, rationing, boundaries, disputes with managers, and the timetable for change.
The pace and nature of change in England, Scotland, Wales and Northern Ireland following devolution and elections to the Northern Ireland assembly worried many.
How did all this square with a national service, they asked.
Dr Chisholm looked confident throughout the debate. But motions containing the words 'no-confidence', 'seek a ballot' and 'non-co-operation' prompted him to his feet to whip GPs into line.
'A national ballot opposing these developments would marginalise us,' he implored before the representatives wielded their red cards in anger.
Dissenter Jonathan Reggler, from Marlowe, Bucks, wanted nothing to do with Mr Milburn's promises.
He said PCGs would prepare the ground for 'healthcare that was wholly finance-led', with PCGs left behind as a last resort for those who could not afford medical insurance.
'Bevan stuffed the mouths of consultants with gold. Milburn has put his hand in his pocket and stuffed our mouths with his loose change. Spit it out. We are halfway there; let's get back to the negotiating table.'
One GP said Mr Milburn's letter was packed with platitudes 'and references to the Labour Party manifesto'.
But when it came to the vote it was clear Mr Farrar could report back to Richmond House that none of the red cards were pointing in its direction.
A motion stating that general medical services cash-limited money should not form part of a unified budget for a PCG and remain the responsibility of health authorities was defeated.
Kambiz Boomla, from Poplar in east London, said: 'I think this has been overtaken by events. The GMSC have done a very good job ring-fencing GMS cash.'
Dr Boomla said the GPs had a 'one-way valve in place' which could increase the cash available for GMS by 2 per cent. 'It's a small loss to the hospital part of the budget, but will make a great improvement to primary care.'
But GPs predicted further conflict with managers. Michael Taylor said south Devon GPs had signed a deal with their HA which allowed them to take the lead in PCGs.
But he was concerned about HA managers in Cornwall.
'I look across the Tamar and the Exe and I see the health authority stuffing the PCG boards with their ilk.'
Forbes Innes from Sefton said GPs were at loggerheads with managers. A ballot of GPs in his area recorded a 61 per cent turnout, with 72 per cent against PCGs.
'Sefton LMC and Sefton health authority have got a considerable credibility gap to bridge.'
Hector Spiteri, from Redbridge and Waltham Forest in London, cited boundary- setting problems with his HA.
Admitting that, in some areas, neighbouring GPs 'distrust and dislike each other', he said the imposition of artificial geographical boundaries would result in the creation of a number of dysfunctional groups.
'We are having great difficulties with our health authority, which wants to impose a division into two PCGs based on a north-south split of the borough when our GPs want an east-west split, which is a more natural division.'
Many GPs were worried that the timetable was too tight for a successful start in April. Suffolk GP Michael Freestone called for a preparatory year. 'This is a very much bigger scheme than fundholding so we need a shadow year.'
Chaand Nagpaul, from Brent, was also worried that the pace of change was being dictated by ministers who saw the direction of travel for most GPs was from PCG stage one to PCG stage four - full trust status.
'We have yet to get a single PCG up and running, yet politicians have made up their own minds about the direction of travel to primary care trust status.
'We will have to make Child B-style decisions on rationing and we haven't the foggiest how this will impact on patient care. I want to see the arrow indicating the direction of travel erased.'
But Chris Robinson, from Norwich, wanted to get on with it: 'We just want to get on and do things. GPs can do it better than the health authority.
'Clinically-led purchasing is a much better bet than leaving it to civil servants and political placemen at trust or health authority.'
Andrew Dearden, from Cardiff, said he was concerned and asked: 'When the money runs out in PCGs, will we be rationing GP appointments?'
'Civil servants will look to set up waiting lists in general practice. If they don't want that to happen they must let us treat patients according to need and not to the dictates of some general economic policy.'