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At the heart of general practice since 1960

GP’s 6-week flu delay

Rob Finch looks at how a former GP and editor of the BMJ used the work of six famous artists to illustrate his visions of the future

Change has been the only constant in the NHS since this Government came to power, with the upcoming White Paper on Care Outside Hospitals marking its 34th major NHS restructuring programme.

This time around GPs are in ministers' cross-wires, with more competition from private providers, changes to registration and further access rules in the offing.

These come on top of practice-based commissioning and the overhaul of PCTs and health authorities, both of which will come into effect in the next 18 months.

With the massive investment of the last few years set to come to an end, the upshot is an NHS in arguably more uncertain a position than it has faced in the last decade at least.

Dr Richard Smith, chief executive of United Health Europe – the US health giant charged with overhauling chronic disease management in the UK – addressed this uncertainty in a recent speech to the National Association of Primary Care.

He outlined six scenarios, each of which he said were ‘plausible descriptions' of what might happen to primary care.

Dr Smith, a former GP and editor of the BMJ, used the work of six famous artists to illustrate his visions of the future.

Jackson Pollock

Abstract paintings made by swirling drips on the canvas

Fragmented and scattered, with a myriad of providers of all shapes and sizes.

‘There will be a multiplicity of forms,' Dr Smith says.

‘Traditional general practice, walk-in centres, a whole variety of online and telephone services, private companies such as MacDonalds and Harrods to cater for every kind of level.'

He said the scenario would lead to advertising and ‘shopping around' between loosely regulated providers, with competition based on access and services. Patients would be likely to make co-payments for care funded mainly by the state.

Jean-Honore Fragonard

Romantic, idealised visions of pretty girls on swings

Dr Smith said this ‘boutique' style of provision already existed in New York and could be exported to the UK.

GPs would work alone or in small teams. Consultations would be long and lists small. Doctors would be always available for their patients, but home visits are low because of the low list size.

Dr Smith says clinicians would be focused more on the ‘social and spiritual'.

He adds: ‘GPs' consulting rooms would be comparatively unmedical – filled with art and freshly-baked pastries.'

Chronic diseases would be the remit of specialists. Health insurance schemes with co-payment by patients would be the norm under this scenario.

Hans Holbein

the Younger

Rigid, formal portraits of royalty

‘This is a world of primary care with Henry VIII running everything. This is a world where practice-based commissioning is taken to its logical conclusion with ever larger practices offering an ever wider range of services,' Dr Smith says.

The ‘dictatorial style' of primary care would require massive budgets and a caste of professional managers employing doctors and nurses who would work to protocols.

Public health would be strongly developed on a tax-funded basis.

Hieronymous Bosch

Religious images of damnation and hellfire

‘This is a vision of hell – the end of general practice,' Dr Smith says. ‘There are no more medical generalists.' Instead, he suggests, all minor illness would be triaged online or by telephone by nurses. They would triage early to specialists working in ‘chambers' or employed by foundation trusts.

Patients with long-term conditions would be directly registered with their own specialist, and out-of-hours services would be provided by emergency care practitioners with minimal medical qualifications.

Raoul Hausmann

Dadaist. Sculpture of a human head altered with robotic elements

Primary care as a high-tech world. Patients, who live in ‘smart' homes with monitors everywhere, start their interaction with clinicians through IT.

Extensive genetic information is available and samples are easily obtained by patients themselves feeding results into a computer.

Cheap technology would reduce the need for staff and their associated costs. Patients would have their ‘human' needs atten-ded by other professions such as counsellors, Dr Smith says.

Marc Chagall

Calming fantasies in stained glass

The ‘utopia' according to Dr Smith. ‘This is a world of time and partnership – very patient-centred, but it's about patients' needs not wants. Working together to a negotiated optimal outcome.

‘It's a very ethical, respectful and cool place, with time to do the job. Science and IT will be there but will sit comfortably alongside human care.'

The Chagall approach would be very patient-focused, but GP-led with maintained lists.

‘Bosch: this is a vision of hell – the end of general practice'

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