ࡱ> EGD *bjbj 46hh!**mmmmm8$ f/111111$UmUmmjmm//@W kd0vmx0"2UUE^* 3: It has fallen to the present reviewers to prepare digests of NHS documents for Somerset LMC over five years now. There has always been a tendency when faced with turgid prose that claims to expound a coherent policy to assume that any failure to detect this consistency must be the reviewers fault. It may well be that the necessary intellectual capacity does hinder a more full understanding but at least a working theory has been formulated: a senior manager recently said in an open meeting that if policy does seem difficult to follow it is because the Department of Health officials are making it up as they go along whilst claiming to have an overarching vision. At risk of riding a hobby horse there is institutional ambiguity at the heart of NHS policy and this is manifest all the way through the system from the lowliest manager who mutters about there being issues around a point but never quite explains what these might be to the text of the long awaited Next Stage Review Final Report. Reading the latter is like drowning in treacle with the substance is hard to detect amongst all the moist sentiment. We were promised more in the second document, Our Vision for Primary & Community Care published a few days later but this also proved a disappointment. Whether one judges that the lack of detail is actually due to policy being made up as they go along or, more sinisterly, because the government has ulterior motives that they dare not honestly announce depends ultimately on ones personal level of paranoia. The underlying theory is that current practice in the NHS is unsustainable and does show coherence in ambition if not in the means of achieving it. The Wanless Report in 2006 argued that, if the NHS carries on as Lord Darzi puts it as it does now simply admitting sick people to hospital, then the projected costs are unsustainable. The population must be engaged in health promotion to prevent illness before it develops. There is a massive public health experiment going on with examples ranging from policies designed to stop people smoking, encouraging more exercise and for people to eat more fruit and vegetables, to the more contentious like offering cardiovascular risk screening to the over 40s, and prescribing more preventative drugs (aspirin, statins, calcium and vitamin D supplements) to otherwise well people. This gets to the very heart of general practice and the different visions that exist for its future. The very expression used by many GPs to dismiss claims for the alleged need for extended hours for example, that it panders to the worried well seems to encapsulate the dichotomy. The worried well could be the really ill in the future so government wishes to spread the health care and preventative net more widely in time and place and, although it would never admit it, does advocate from the medical professions perspective at least a never mind the quality, feel the width NHS. Examples already seen include the replacement of highly trained councillors with graduate mental health workers and the reduction of the number of doctors involved in the Drugs Service whilst promising better services. Experience from other parts of the country has shown how APMS contractors often soon reduce the number of doctors sessions originally agreed when a contract is signed. Examples in social care from South Lanarkshire in Scotland have revealed that tenders are granted to the lowest bidder despite lipservice paid to the importance of quality and there have been allegations of scandalous abuse by private companies cramming hours of paid-for care into a few minutes so that tight profit margins can be maximised at the expense of service-users. A House of Commons committee only last week criticised the reduction in dental care seen in many areas with the introduction of the new dental contract but, of course, the answer is always to wait a little longer and all will come right in the end with this stronger platform for developing services. These documents do give some welcome praise to the achievements of practices and the benefits of the new GMS contract since 2004. There is talk of the gains made under the Quality & Outcomes Framework but that this should be renegotiated to take more recognition of preventative measures at the expense of practice structural domains. Hence the slow emergence of the practice quality assurance tool to compensate if not financially but rather to permit practices to continue to exist on the level playing field with new providers. There is also the concept of locally agreed QOF domains taken from a centrally agreed menu. Despite this progress there are still shockingly varying levels of satisfaction and although most people greatly value the continuity of care provided by their GP practice (sic), there are those (particularly younger people and those in fulltime work) who would like a more flexible range of options for accessing primary care. Hence the investment in GP-led health centres that are to supplement and not replace existing practices but will be better than them in terms of easy, no questions asked access. In contrast, it is also clear that...people increasingly expect public services to do more to treat them as whole individuals rather than for isolated symptoms. The DH will promote responsive primary and community care services that systematically listen to and act on the views of patients, presumably even when they are mistaken. However, this will not be a problem because of course another important duty will be to help people make the right choices for all the repetition of the mantra of personally tailored services. Talking of these, technological advances will help people with chronic conditions to monitor their blood sugar or oxygen saturations at home and send the results over the phone to the community matron who will act swiftly if there is cause for concern by following the pathway outlined in the care plan that will have been offered to all patients to help them take control of their health. The public will be able to get more information about practices through more data being available on the expanded NHS Choices website and the government will support the local NHS, working with local GPs, to give the public a wider and more informed choice of...practice. There is, in fact, no explicit pledge to abolish practice catchment areas other than ones judged to be narrow, where being on the wrong side of the street might exclude one from registering, but this has been implied in press briefings. To balance there is a pledge to develop fairer rewards for expanding practices as at present most practices receive historic income guarantees that do not necessarily bear any relation to the size or needs of the...population they now serve...We will work with GP representatives to channel more resources into fair payments based on the needs of the local population served by each practice. The implication is that well off practices with closed lists will have to open them and offer more responsive services to more patients in order to retain income but how this fits in the quality agenda let alone with the equality of levelling up spoken of by the Prime Minister is harder to see. In terms of energy and commitment expressed for any scheme one management model posits the division of individual responses into four groups. There is in fact much to commend in these documents not just for the players to engage with and the cynics to scorn but also for the spectators and even the living dead (keeping their heads down and hoping it stays away until after they retire) to welcome. But the devil will be in the detail and recent experience of the governments idea of working with professionals does not bode well. On the day that the second document was released Mr Ben Bradshaw the health minister announced that some GPs had what he called gentlemens agreements not to take patients from neighbouring practices thus deliberately inhibiting patient choice. A few days later he was taken to task on Radio 4s Any Questions programme by the chairman Jonathan Dimbleby. Bradshaw had already backed down by claiming that this, in fact, affected a very small number and that it was by no means the greatest obstacle to patient choice but despite the BMAs refutation of his claim that he had never received so many emails in support on a given subject. To his credit Dimbleby pursued the minster. How many emails does that mean? Is it ten, a hundred, a thousand, ten thousand? Bradshaw replied, More than ten. He was jeered by the audience.     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