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A hub-and-spoke future

If you decided to set up primary care now, you would not come up with the current model.

It perpetuates divisions between members of the primary healthcare team, other practices and hospitals, and encourages professional isolation. Patients feel they have to justify seeing a doctor and find the service unresponsive to their needs and wants. Only a move to a salaried service can change this.

The most workable model would be to have GPs working consultant contracts in large units with a hub-and-spoke organisation. Each spoke would be a fully integrated multidisciplinary primary care team, linked with its local authority, caring for all patients within a geographical area. The hub would consist of an intermediate care unit plus management.

An alternative model would be for practices to continue as present but with GPs employed by PCTs, directly managed and fully integrated with other elements of primary care, but it is unlikely this would be sustainable long-term.

Under the current model the first point of professional contact in the NHS is with a GP. Many GPs feel frustrated that their skills are used seeing large numbers of minor clinical problems simply because the patient has no real alternative. An integrated primary healthcare team could allow patients to see the person most suited to their needs and free up GPs to see complex cases, many of which would need GPs with enhanced training to manage them.

An employed contract would allow proper CPD and appraisal. At present we do CPD in our own time, fitted in between everything else. Appraisal is too often a case of do it and forget it until next year, when it could be a real tool for assessing what we actually do in front of the patient. This needs the HR skills of a large organisation.

Similarly, we spend a lot time on running the business. As employees, that would be someone else's headache, leaving us a session a week for the clinical administration we really do need to do. Career progression could take place within a big organisation and extended hours could be done through shift work rather than longer hours.

The advantages would be considerable - security of tenure, locums provided, employee rights on maternity, sickness and redundancy, access to skilled management and HR, right of redress in disputes with colleagues and a right to say no to limitless stress-inducing workload.

From Dr Paul Caldwell, Goole, East Yorkshire

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