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These are simple answers, but the wrong ones

Guest editor Professor Chris Salisbury offers his take on the week's news

Guest editor Professor Chris Salisbury offers his take on the week's news

The journalist H L Mencken said: 'For every complex problem, there is an answer that is clear, simple - and wrong.' General practice is full of complex problems. How can we improve access without harming continuity? How do we improve quality of care?

There is no shortage of people ready to recommend simple solutions. Amalgamate small practices. Widen opening hours. Pay for performance. Increase competition. Delegate. Specialise.

This week, we highlight some of the organisational changes having an impact on general practice.

But how do we know which of these are real progress and which are simple but wrong?

Primary care is based on a series of interconnected principles, such as providing easy and equal access to healthcare, through a single point of first contact.

It's also about treating people as individuals, not as collections of diseases, and recognising that most patients value advice from a known and trusted professional. Changes that don't promote these principles will undermine the whole basis of general practice.

So we should seek to improve access through extending hours, if we can do this in a way which doesn't threaten other principles.

The results above are encouraging. They suggest most practices are entering into local arrangements with PCTs to extend hours, which are presumably more sensible and flexible than the original national scheme.

We should also support moves to provide a wider range of services locally, because that promotes the principle of comprehensive primary care. But rapid expansion of multiple points of access and walk-in care for unregistered patients, as we also reveal this week, undermines co-ordination and depersonalises care and is likely to lead to reduced quality, duplication and inefficiency.

It's a simple solution to the problem of increasing access. Simple, but wrong.

And the consequences for hospital referral rates, NHS expenditure and patients are likely to be poor.

The controversy about recent changes in primary care reflects differing views about the real importance of traditional values such as continuity of care, as shown in the debate on page 20. A PCT manager recently told me he thought the doctor-patient relationship was largely a myth propagated by GPs to justify their existence. I suspect such views are common among primary care decision-makers, most of whom are relatively affluent, healthy and working. But these are not the characteristics of the people who most need general practice.

Rather than defending ourselves against external threats, our best hope for the future is to keep improving the care we provide in line with primary care values. In this guest edition we highlight new evidence on ways we can help our patients, about what works and what doesn't.

These are the changes that matter.

Professor Salisbury is professor of primary healthcare at the University of Bristol and a GP in the city

Guest editor: Professor Chris Salisbury Professor Chris Salisbury, guest editor of Pulse's October 15 issue

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