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At the heart of general practice since 1960

PCTs slash drugs misuse service pay

Cato Pedder talks to GPs about the growing threat

to interpersonal care and the need to safeguard the generalist role

An old woman shuffles hesitantly into the consulting room. A GP, hunched in the corner, looks up to offer a quick good-morning, before his eyes are drawn back to the computer screen. It is another 10 minutes before he looks at his patient again ­ and then only to say goodbye.

This was the experience for Dr Mike Parks after agreeing to take part in the primary care clinical effectiveness scheme, or PRICCE, the prototype of the quality and outcomes framework. Increasingly it is becoming the experience of GPs up and down the land.

In Pulse's Agenda 2005 survey, three-quarters of GPs had serious concerns over the future of general practice. GPs are worried that 'tick-box medicine' is disrupting their contact with patients. They

also believe the GP generalist role as the patient's advocate and care co-ordinator is being undermined.

'Having a computer in the room is like having three people in every consultation,' says Dr Parks, medical secretary for Kent LMC. 'It has got in the way of the old-fashioned patient-focused agenda.'

An evaluation of PRICCE back in 2000 warned the 'zealous concentration on chronic disease management' could lead to the neglect of psycho-social problems.

Nearly a year into the new contract and the warnings do not seem to have been heeded. GPs are having to farm out elements of care to practice staff in a bid to hit targets ­ increasing the distance between doctor and patient.

In Pulse's survey, 91 per cent of GPs said the GP generalist role needed to be defended to prevent further damage to continuity of care.

Professor Martin Marshall, head of the division of primary care at the National Primary Care Research and Development Centre, observes: 'We are living in a society that increasingly values specialists. We have some policy- makers who simply don't understand generalism.'

Research by the centre has concluded the Government's policy of creating new capacity within primary care by using specialist GPs and nurse practitioners could cause 'fragmentation, duplication and increased overall cost'.

Yet the Government shows no signs of rethinking its strategy. In the past few months, it has announced the introduction of community matrons and commuter clinics, and plans to extend independent prescribing powers for pharmacists and nurses, all of which can be seen as a threat to the GP generalist role.

Dr Mayur Lakhani, chair of the RCGP, describes a future where general practice is just one of many entrance points to patient care, all of which could refer patients to an independent provider or discharge them to the care of a community matron.

'It could increase the risk of delayed diagnosis or side-effects because so many people are involved in the care of a patient,' says a worried Dr Lakhani. 'This is where the co-ordinating role of the GP is so important.'

Few GPs question the need for primary care to change to cope with an ageing population and the increasing burden of chronic disease. The question is how to manage that change to preserve the generalist role.

Policy experts claim the change must come from within primary care, not from outside. Dr Tony Snell, former NHS Confederation contract negotiator and one of the architects of the quality framework, argues mo- dels of chronic disease management range from those 'done by' GPs to those 'done to' GPs.

Professor Aneez Esmail, professor of general practice at the University of Manchester and a GP in the city, says GPs are ideally placed to co-ordinate care that could otherwise become fragmented.

'The notion that the same doctor provides care through your illness is in great danger of disappearing,' he warns.

Back in Dr Parks's Dover consulting room the impact of such policies is more personally felt.

He points out that having regular contact with patients provides more than just increased patient ­ and GP ­

satisfaction.

When a young woman has seen her GP for contraceptive advice, then later in life for antenatal care, she is likely to be much happier to come forward with more serious problems, such as breast lumps.

'The trouble is you can't count that. You can count the number of diabetics in a practice,' Dr Parks says.

'We need to be aware of the risks of losing intangible but important qualities.'

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