At a recent House of Commons gathering to discuss the role of commissioning in delivering improvement, there was silence on the application of world class standards to the commissioning of primary care.

The debate was framed as though commissioning were limited to hospital services. The first question was about the impact of world class commissioning on services for the homeless. The response from the most entrepreneurial GP on the panel was that he didn't really get paid enough to be concerned with the health of the difficult, but an offer of a local enhanced service might stimulate some interest.

Apart from the breathtaking callousness of the answer, it reinforced the risk of failing to apply the same standards to the commissioning of general practice as will increasingly be visited on the rest of the health system.

General practice has been the bedrock of the NHS. It is critical to the early identification of disease, advice, treatment, long term management and onward referral.

Its role is so central that variation in primary care has the potential to affect the health outcomes of whole populations. GPs play a key role in tackling or sustaining health inequalities. A map of chronic heart disease morbidity in Birmingham surprisingly demonstrated highest concentrations in areas of greatest affluence, whereas mapping mortality reproduced the areas of greatest deprivation.

GP competence

The morbidity map, based on quality and outcomes framework data, was really a map of GPs' competence and organisation in the identification and consistent management of chronic disease. Where that fails, people die.

Although the sector has a proud tradition of scoring highly for public respect and in relation to satisfaction with service in successive national surveys, there is clear evidence of lower satisfaction among black and minority ethnic patients, who are typically concentrated in urban areas where primary care is most overstretched. These patients tend not to change their GPs, partly because lack of information means they are unaware they can move.

In a recent survey in the West Midlands, 60 per cent of respondents said they received most of their information about local services from their GP. This is great where practices are positively signposting people into a range of local community-based alternatives, less so when they are choosing to frighten older patients in well served areas about non-existent threats to the local practice.

The traditional model of general practice may also lead to underinvestment in other areas of primary care, where pharmacy or nursing may provide safe, responsive alternatives to the doctor. Primary care is probably the biggest, most underdeveloped market for diversification in healthcare. This is not just about bringing in large commercial players, although in areas the GP has long avoided, that will be part of the solution.

Transactional relationship

While the GP contract has had a significant positive impact in incentivising quality of care, the model of a series of additional "special" payments has also had the perverse effect of reinforcing a transactional relationship between primary care trust and contractor.

This is the Naomi Campbell effect - if not quite not getting out of bed for anything less than $10,000, then encouraging practices to make differential decisions about which client groups and interventions they can be bothered to undertake. This is of course the opposite of holistic continuity of care. It is a scandal when Xp per registered patient is regarded as insufficient to cover changing a patient's dressing and people are sent back to hospital, or the PCT has to establish district nursing clinics instead.

Of course the majority of practices are highly committed and flexible, active participants in a more strategic approach which seeks both population health improvement and excellent individual experiences. However, the venality of the minority does huge damage to the profession's reputation and standing.

In this context, the application of the world class commissioning competencies has huge potential to bring the best of general practice to the most disadvantaged populations and improve the already good experiences of the majority.

While the historic focus has been on the technical proficiency of the practitioner, the public has made it clear it regards dignity, respect and effective communications as being key to a successful healthcare intervention. Increasingly we shall expect health professionals to evidence effective communication skills as rated by their patients.

Peer review

GPs respond well to information. The quality and outcomes framework, supplemented by activity data and patient feedback, needs to be made more available to practices, supporting peer review and benchmarking, enabling practices to develop their own measures for local improvement. We need to enable patients to make informed decisions about registration and streamline processes which support them in changing their primary care provider where they choose to do so.

This requires a more open sharing of information on available services and their performance and ready access to the registration team.

Commissioners will need to act on evidence of consistent poor performance over time. If we are now commissioning primary care, rather than administering a national contract, we can presumably decommission failing services.

General practice has sought to distinguish itself from large commercial companies, while hanging on to its long-standing private independent contractor status. In the context of world class commissioning, it will have to demonstrate this independence is compatible with the delivery of national policy and local PCT priorities as part of the NHS family, or take the consequences of open competition. There may be more supermodel tantrums to come.