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Education And Debate

Primary care: opportunities and threats: Distributing primary care fairly

BMJ 1997; 314 doi: (Published 22 February 1997) Cite this as: BMJ 1997;314:595
  1. Mike PringleIona Heath, professora
  1. a Department of General Practice, Queen's Medical Centre, Nottingham NG7 2UH

    An opportunity to improve primary care

    The new legislation based on Primary Care: The Future. Choice and Opportunity1 offers flexibility in the methods used to provide primary care services in England and Wales. Providers perceive more threats than opportunities. Though no changes are without pain, the greatest threat may well be to general practitioners' complacent assumption that all will be well if they are left alone to continue as they are. This article argues that there are systematic problems with the current system of delivering primary care which may be addressed through new ways of designing and delivering services.

    “It ain't broke, so don't fix it”

    There is a contention that primary care is doing just fine and there is no need to change it. In particular, there is no reason to destabilise it with innovations in service delivery, even those that have been evaluated. Such complacency runs counter to the reality of primary care experienced by patients and health service managers throughout Britain.

    There are still practices which provide poor quality clinical care-such that general practitioners would not recommend them to patients who are moving. There are still practices that offer an inadequate range of services-no screening, prevention, family planning, and minor surgery-while the doctors pursue a strategy of high list size and high personal income. And there are practices where health service resources are wasted through high referral rates,2 poor prescribing,3 4 5 and inappropriate investigations6 or through inefficient catchment areas.7 8 Provided such practices comply with their conditions of service, the health service has neither the will nor the way to stop contracting with them.

    And then there are the restrictions that prevent other practices from enhancing their quality of care-for example, the inability to move resources with patient care; the limitations on changing skill mix (such as replacing a retiring partner with a part …

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