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Is GP work shift a grand illusion?

Just over a year ago, the Government proposed a seismic shift in the organisation of the NHS, with at least 5 per cent of funding to move from hospitals to primary care.

The aim set out in the Our Health, Our Care, Our Say white paper was to bring care 'closer to home' with a series of initiatives to improve local services.

At the time, GPs were welcoming and sceptical in roughly equal measure, with many unconvinced money could ever be prised from hospitals. So has anything changed, or was this just another piece of grandiose Department of Health rhetoric?

The department insists it has made good progress on the targets it set itself in the white paper, with the launch of a series of community-based care pilots and an apparent determination to force through real changes to the structure of NHS finances.

But some experts are unconvinced. Dr Jon Glasby, head of health and social care at the Health Services Management Centre, University of Birmingham, was sceptical of the

white paper's thinking when

it came out.

A year on, he still sees finance as one of the biggest problems, believing funding for hospitals has always come first.

'How do you invest first in community services to make sure they're safe? You can't close hospitals and then put

in place community services. With the current financial situation, that's difficult.'

Others are unconvinced the department has its maths right. Professor Roger Jones, professor of general practice at King's College London, fears general practice will become less cost-effective as it takes on more work.

'A myth grew up that anything in primary care was going to be cheaper and that is still quite widespread,' he says.

'I think we have to start off by questioning that. Primary care has a special function – it's a gateway system, and you can't just add or take things away and assume it will continue to be cost-effective.'

One Government initiative to shift care over is the use of GPSIs, but Professor Jones is sceptical. An evaluation of a GPSI dermatology service last year found it was more expensive than hospital care.

Professor Jones warns: 'Creating mini-specialists threatens the gate-keeping system. I don't buy it as a health plan. How do GPs know what an appropriate case is for GPSIs?'

Dermatology is a key area, and one of the six the Government has chosen for special

pilots designed to provide an

evidence base for shifting care.

Five pilots each in dermatology, ENT, general surgery, orthopaedics, urology and gynaecology have been set up, and the outcomes will be reported in the summer.

More questions

Dr Robin Graham-Brown, chair of the department's care closer to home working group, says its analysis so far has thrown up a series of questions.

'We'll need to explain the

implications of the potential

reduction in critical mass we have in hospitals. If there's

insufficient work to support the present infrastructure, will

patients with more serious,

rarer diseases and those requiring higher level management have to travel further and further as centres close?'

Investing in community

hospitals is another way of shifting care. Five months after the white paper, the NHS

announced £750m of capital funding over the next five years for a 'new generation' of community hospitals, but there are doubts about where the cash has gone. GPC negotiator Dr

Peter Holden complains: 'We have seen none of it.'

The Government plans to release further guidance for PCTs in the summer on community hospital development, but Dr Holden believes PCTs are reluctant, because faults in the tariff system put the hospitals at a financial disadvantage.

'The problem is the inability to split tariffs. PCTs who have community hospitals are getting out, because the district general hospitals or foundation trusts get the full tariff, so you end up paying twice. It's a faulty tariff system,' he says.

The Government says it intends to unbundle the tariff and extend it to the community from 2007/8. The purpose of 'unbundling' is to provide incentives for GPs to compete with hospital 'bundles of care' by providing individual parts of the care pathway such as diagnostic testing or rehabilitation.

Getting incentives right is a crucial issue for GPs.

Dr Pawan Randev, a GP in Ealing, west London, says GPs cannot take on more work in the community unless they see new resources. He warns: 'GPs have played that game too long.'

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