Changes to contracts, guaranteed appointment times, too few extra doctors. . .GPs are getting down to some serious grumbling on the extra pressures they say the NHS plan will bring to the profession. Ann McGauran reports

You can't always get what you want. Unless you are a patient seeking a swift GP appointment in 2004.

The chance of a consultation within two days is one of the NHS plan's proud promises. It will delight the public, but GPs don't feel they've been quite so lucky.

Primary care appears to be getting what the government thinks it needs in order to make such a speedy response deliverable.

But the profession's leaders say 2,000 extra doctors over the next four years and 450 more in training comes nowhere close to the level of GPs required to deliver access to primary care targets.

According to the Royal College of GPs and the British Medical Association's GPs committee, there was already a planned expansion of 1,100 over this period, 'so this represents a new commitment to only 900 new GPs by 2004'.But committee chair Dr John Chisholm is calling for a much greater expansion: 'We need to see a very significant growth in the number of GPs.

'I would want to work towards something like a 30 per cent increase.'

His estimate was backed by RCGP chair Dr Mike Pringle, who adds: 'We were hoping for more GPs and a clearer commitment made to the value of general practice.We want to have discussions with the government to work out a more realistic increase.'

Why are both GPs' bodies so 'profoundly disappointed'? The answer lies in the extra demands they believe the NHS plan places on their members. The GPs at a - probably refurbished - surgery near you will be much more likely to specialise by 2004.

The plan talks about less pressure on primary care doctors' services because a 'new generation' of nurses and other primary care workers will be taking on more of the tasks currently done by GPs.

But Dr Chisholm reckons a number of factors are combining to make the patients' appointment wait target unachievable nationally.

These include patients seeking longer consultation sessions than the current average of eight minutes, which could 'only be achieved by GPs having fewer consultations' - and the trend towards part-time working requiring 1.5 GPs to replace every retiree.

Doctors' leaders believe that pressure will also come from the bigger role they will play locally as primary care trusts become universal and new care trusts incorporating social services and health services emerge.

'Increased demand is also going to come from the levelling up of quality and shifting work from hospitals towards the specialist GPs and intermediate care, 'Dr Chisholm adds.

'The national plan wants to share the work out, but there are no quick wins as there is a considerable recruitment crisis in the nursing profession.'

Is a massive burden being lifted from GPs' shoulders or are they going to drown in extra work as a result of the plan? There is no meeting of minds between doctors and the Department of Health on this fundamental point.

A DoH spokesman says half of GPs are already achieving the 48-hour target for appointments. 'It's not just a question of sheer number of doctors - it's about the way they work, 'he adds.

Fulfilling patients' wants is what the NHS plan is all about, and public consultation established that ending the postcode lottery for treatment was in the top ten of issues the public wanted addressed The government sees moving 'the majority' of GPs to new personal medical services contracts by 2004 as one of the keys to flexible and equitable services across England. By then - in what the plan calls 'the most significant change to the way GPs work for the NHS since 1948'- both traditional national red book arrangements and local PMS contracts are set to operate under a new 'single contractual framework'.

Under PMS, doctors can choose to become employees, and this suits many of them. The DoH told HSJ that the second wave of pilots was 'massively oversubscribed' and GPs were 'voting with their feet'.

Chief executive of the National Association of Primary Care Clive Parr reinforces that view and says there is a great deal of interest in the scheme.

But many GPs view this trend as a threat to what many of them value most - their status as self-employed independent contractors.

The BMA's GPs committee certainly does not share the plan's glowing opinion of PMS. Dr Chisholm says: 'I am baffled by its enthusiasm. In a sense the new contracts give the government less control over the consistency of services. The first-wave PMS pilot is not yet complete. Rather then hastening too fast it would be better to move in a more careful and considered way.'

The profession is seeking reassurances that parts of the NHS plan will not be pushed through early under the national core contract for third-wave PMS schemes.

That contract - effective from next April - is to be published in the next few months and the GPs committee wants consultation over its contents.

Worries also exist about asking sole practitioners to meet separate red book quality standards or be forced on to PMS contracts. The feeling is that this is an over- reaction to the Shipman case.

'It's simplistic to say that single-handed practitioners are a problem, ' Dr Chisholm says.

Manchester GP Dr Martin Seely takes a similar view. He announced last week that he was prepared to bring his opposition to this aspect of the plan all the way to court.

The plan reveals that the medical practices committee is soon to be abolished. A new medical education standards board is to take over the job of tracking the number and distribution of doctors in primary care.

The MPC will be replaced with a 'single resource allocation formula covering all NHS spending including general medical services non-cash limited expenditure'.

By 2003 there will be a 'new way of distributing resources to address inequities in primary care services'.

NHS Confederation policy manager for primary care Jane Austin believes the government is 'trying to improve co-ordination' when it comes to spreading doctors more evenly to meet needs.

But she stresses that health authorities would have to 'second guess' the gaps in the plan as there are still many unanswered questions over 'who would control, who would fund and how it would work in practice'.

And Dr Chisolm flags up the need to educate the public about when to see a health professional in an NHS where the concept of demand management is 'largely neglected'.

He says: 'We are still going to have to prioritise and make choices.'

The wish list: what GPs want Dr Hamish Meldrum, joint deputy chair of the BMA's GPs committee, gave HSJ his 'top five' wishes for the next four years:

30 per cent increase in GPs - an extra 10,000 rather than the 2,000 in the NHS plan;

more health service staff 'across the board' above NHS plan levels;

no 'victimising' of single-handed practitioners;

no forced move out of 'tried and tested' traditional contracts;

to educate the public on how and when to use the NHS;