The real question is how all of these changes have affected doctors and their ability to treat patients. Since 1987, many evaluations of GP job satisfaction following changes in primary health care have been conducted. These have showed that job satisfaction fell after the introduction of the 1990 contract but had partially recovered by 1998 10. Between 1998 and 2001, satisfaction fell once again; this could be due to the termination of fundholding, the implementation of clinical governance to improve quality of care, the introduction of walk-in centres and NHS Direct.
As for the effect on patients, even the most sophisticated form of fundholding, “total purchasing”, has had little effect on clinical outcomes, the shape of secondary care or overall costs. Specific targets in the NHS Plan for patients to see a GP within 48 hours has resulted in people waiting less time for an appointment. General Practice is currently under a lot of pressure. This is partially due to other changes within the NHS; there has been a reduction of 21,000 hospital long-stay beds since 1983 and the average hospital stay has decreased from 16 days in 1990 to just 7 days in 1999 2.
As a result, the management of patients has shifted from hospitals to GPs 11, as more patients are looked after at home. Also, there is a rapidly increasing number of much older patients, usually requiring treatment for multiple illnesses: by 2024, there will be 40% more people aged over 85 years. Money spent on general practice has risen by 20% during the last decade; however, money spent on hospitals has increased by more than 60% in the same time period. Because of this added pressure facing general practices, changes are essential.
One major simple change for the future that has proved to be very helpful is the introduction of nurse practitioners to provide care at the first point of contact in a primary care setting. A systematic review by Sue Horrocks et el 12 involving 11 trials and 23 observational studies concluded that the availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care. I also see the future of primary care within the NHS to be highly supported by information technology (IT).
In a BMJ article (January 2003) 13, a professor for primary care made a list of how he could foresee IT changing primary care for the better. Some of his ideas were to send discharge summaries and clinic letters electronically, to allow hospital diagnostic codes to be sent to practices electronically and to allow the electronic transfer of records between practices. I believe the NHS is going to have to invest a lot of its budget into IT, as the demands of GPs are now so great, one of the only viable solutions is to have IT at their fingertips.
There are many changes the NHS must make in the future in order to become more primary care led. Although the White Paper is very confident of this primary care led future, there is evidence to suggest that GPs feel otherwise. Their attitudes to the policy suggest that progress towards a primary care-led NHS will continue “to be patchy 14”. The limited shift from hospitals to general practice so far in addition to evidence of unsure attitudes to the shift on the part of GPs, lead me to believe that this is a policy objective that may never be achieved.