Regional change agent Dr Bill Barker explains how the NHS Plan will affect guideline development and implementation not only for primary care but also for secondary and tertiary care

The NHS plan is extremely long and difficult to read and I am sure that most GPs will not have the time to do this. However, the plan has far-reaching implications for general practice. For example:

  • There will be 2000 more GPs and 450 more being trained by 2004. Where are these doctors coming from and what incentive will the NHS provide to persuade them to enter general practice?
  • GPs will all be in either PCTs or some form of care trust (the step after level 4 where health and social services work together) and will have a greater role in commissioning services.
  • More work will be done in the community and extra, better qualified staff will be there to help GPs. There will also be an occupational health service for GPs and they will have specific funds for professional development.
  • The red book will be revised to encompass quality markers, rather than measure quantity markers, which will be related to pay. This will allow more flexible working for individual practices. Single-handed practices will also have to change the way they work; if this proves impossible via negotiation, then a PMS-type contract will be introduced for them.

These are just a few of the issues raised by the document, but the writing is on the wall for general practice as we know it. Quality issues, linked with performance management and backed up by sticks and carrots, are on their way.

My premise is that if we, as a profession, have started upon the process of addressing quality rather than quantity, and demonstrated that we are able to work together to produce a service that is patient based and oriented, then we are well on the way to deciding our own future.

Consultants will also have the same pressures to face over the next few years. They will also have different changes, either negotiated or imposed on them, and will have the same quality issues to address in secondary care.

Alongside this there is major change associated with NICE, clinical excellence and health improvement targets, and the development of intermediate care. This will result in changing workloads and patterns of working for primary and secondary care.

General practice should, I think, start the process. In order to do this, we need to first look in house at how each practice works in order to understand the system before we begin the changes.

Then, we need to look at how, as a group in primary care, we work, to see how this needs to change in order to adapt and grow for the future.

Also, we need to understand how we interreact with secondary care, then develop guidelines and pathways of care that can be managed with the appropriate local consultants.

This will aid both groups, as secondary care providers will also have to implement guidelines and pathways of care locally. Both of these will be challenging for all concerned as change is never easy, and primary care is being asked to change in many areas at once.

Also, the shifts of responsibility for commissioning will cause difficulties when trying to develop these strategies.

Guidelines within practices are especially difficult, because they are usually developed with time and experience and are flexible to allow patient choice and clinician preference. Faced with this type of change, we will all need to work together to develop guidelines that can be shared across practices.

I believe that very few practices will be able to develop suitable guidelines that fit within new central guidance in time to meet the Government's schedule. The only way to achieve this is to split the workload across practices and share the results.

If we do not do this, there will be some practices or areas that logistically have either further to travel and will never arrive, or who, although already started on the process, have not got enough manpower to get to the end. An example of the latter would be single-handed practices.

This means that practices will have to share and also accept work that has been done by others. This may be difficult for some practices. However, if this is not achieved, then guidelines will be implemented by others, which may have been developed elsewhere and may not be as appropriate for that area or practice.

Guidelines that cut across primary and secondary care will also have to be developed. These are going to be more of a problem because they will need agreement across the whole of a health economy. We also have to consider the impact that these changes will have on social care services.

A further difficulty is the comparative pricing structure that exists for some types of drugs, which may be available at a different cost structure in secondary care. This may have an impact on the prescribing budget from which the primary care performance incentives are developed.

Another problem will be the expectation that various types of disease will be actively identified within communities, e.g. ischaemic heart disease. An increase in the number of patients identified leads to increased prescribing in that area. If the drug of choice is the most expensive in the community but the least expensive in secondary care, then the drugs budget is in big trouble.

It is therefore doubly important to look at areas that have a potential for growth – either because they are under-diagnosed or under-treated, or because they have a high cost differential – as these drugs and guidelines, once sorted, will mean we are adopting a safety strategy for the future.

If practices do not adapt themselves, changes may be imposed. And if they are imposed they may not fit in with the local policies, and may cause conflict between secondary and primary care. They may also blow a hole in the financial arrangements for the area and leave you in more trouble.

I believe there is only one. As a profession, we have sat back for too long: we now need to take a hold of medicine and deliver it to the best of our combined abilities.

Plenty of good projects have been carried out nationally. These, and others that have been supported by outside agencies, could be implemented, either as they are, or adapted to meet local requirements.

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Guidelines in Practice, November 2000, Volume 3
© 2000 MGP Ltd
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