This is the text of an e-mail I sent to the BBC. Comments welcome.
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In this morning's Today programme Richard Hannaford said that although there
was some GP opposition to PCGs, most GPs were in favour.

Later in the same programme, I gather that the Minister of State expressed
the identical view. Is this a coincidence?

There has not been a proper test of GP opinion on this subject. The most
extensive test of GP opinion (by "GP magazine" a few weeks ago) revealed 91%
opposed to the changes. Some of those 91% may be merely apathetic, but the
statement by Mr Milburn, and its regurgitation by the palpably "spun" Mr.
Hannaford is simply untrue. A national ballot is required to establish the
true feeling of the profession (this is opposed by the GMSC).

If the BBC is interested in going deeper into this story, then I suggest
following up on the the following...

1.The growing hostility of GPs to these changes.

2 The growing hostility of GPs to the BMA and GMSC who welcomed the White
Paper without consulting the profession. There is a growing clamour for a
national ballot about cooperation (or otherwise) with the White Paper
reforms.

3. The medical profession never felt inhibited from opposing Conservative
changes to the NHS. Now the BMA's view seems to be "they've got a huge
majority - it's going to happen anyway - we'd better get on with it". This
is in spite of 91% grass-roots opposition don't forget.

4. The lack of guidance from the D0H. The latest HSC (HSC 1998/65) was pure
waffle - civil service speak.

5. The lack of pump-priming money to get PCGs going.

6. The sheer difficulty of getting all of these self-interested groups
(doctors, nurses, health visitors, midwives, opticians, dentists,
phamacists, community health councils, local authorities and social
services) to work together for the common good. To believe that this could
work is to believe that previously competitive or adversarial groups will
suddenly acquire a deep belief in collectivism and will abandon
self-interest for the common good. Does this sound extreme? At a recent
meeting of GPs meeting in my town to discuss the formation of an
out-of-hours co-operative, feelings ran so high that furniture was thrown!
The recent midwives conferences recently called for GPs to lose their
payments for maternity services. Politicians underestimate the tensions
within and between the various pofessional groupings. Closer ties might be
desirable in many respects, but to force us together by next April is akin
to an arranged marriage. A longer courtship would be much better.

7. There is absolutely no way that either I or my Health Authority contacts
can see to make wayward practices toe the line in terms of following PCG
protocols, prescribing guidelines or any other broader policy goals. As a
result a few profilgate doctors will be able to squander the efficiency
savings of the prudent. Unless we all try to make this work it will fail
because there is no motivation to make sacrifices or hard choices if you
cannot rely on your collegues to do the same. There is no concievable
mechanism to enforce compliance that does not involve denial of clinical
freedom and personal judgement.

8. More than 50% of GPs were fundholders until very recently (they are
currently falling like flies). Being given a budget engenders a certain
pride of ownership and a sense of responsibility. It is powerful motivation
to look for efficiencies and say no to frivilous patient requests. Once
budgets attach to localities rather than individual practices the motivation
will be gone. I predict that referral activity will accelerate as will
prescribing costs. Marginal savings in administative costs will be more than
offset by a release of pent-up patient demand.

9. Part of the political dividend from this process is that PCGs will be
left to make the hard rationing decisions. Officially rationing doesn't
exist, but of course it does. What was the Child B case about then if not
exactly this? In future it will be PCG members or their appointees blinking
into the TV lights or appearing before a Commons select committee. Ministers
will have the luxury of saying "nothing to do with me guv!" or critisising
the judgement of doctors doing a job that the never wanted and for which
they are ill-equippped and under-prepared.

10. Different practices in the same town complete for patients in order to
make their living. PGCs will control the allocation of GMS budget between
practices, and are thus in the position to improve or withdraw services from
a particular practice. This will be a source of frequent and bitter dispute!

11. Once the patient services and GMS budgets are unified, and in a tough
spending year, doctors running the PCG may have to choose between cutting
patients services and forgoing personal income. When did this ever happen to
health service managers or politicians?

12. These changes could change the nature of General Practice for ever -
away from the practice-based system towards larger collectives that pool
their resources. Good or bad, these changes will be fundamental and should
be debated. Many (myself included) would argue that we should fear any
reform that threatens role of the "cradle-to-grave" family doctor with a
long-term personal relationship with his/her patients. Extending the role of
nurses or other para-medical professions as a cost-saving exercise
undermines the pivotal role of the GP and will work long-term against the
interests of patients.

13. When in opposition the Labour party complained that the Conservatives
had not piloted fundamental reforms (the internal market). This standard
does not apparently apply to the Labour party in government.

14. GPs are being blackmailed into working on the fledgling PCGs - most
currently see participation as a defensive strategy. It is starting to take
a lot of time and is currently being done without remuneration. Running the
health service for free is not in the Terms and Conditions of Service for
Doctors in England and Wales.

15. Many feel that there will be a move before long to make all GPs
salaried. Plans to end self-employed contractor status would fit comfortably
with the government's desire to wrest control of primary care from the
profession. I and many collegues would regard forced salaried status as a
resignation issue.

16. In 5 to 10 years time, General Practice will be fundamentally changed.
The personal service of a family doctor, and his/her ability to tailor local
services to patient needs will be much diminished. GPs will be much more
controlled from the centre and their importance in the public sector will
have been reduced. There is a real danger that GPs will seek to reduce their
reliance on the public service, in order to maintain their status, income
and professional freedom. This means more private, insurance and
occupational health work. Many may choose to leave the profession or seek
work abroad. There are already studies which show medical students rejecting
a career in General Practice as a result of the White Paper.

These are BIG BIG changes - far more significant in their own way that the
internal market, which enhanced rather than diminished the importance of
individual practices. Serious journalists must stop repeating untruthful
ministerial statements and look deeply into the background.

Someone should be thinking about doing a Panorama programme on this
subject - it could be sensational and controversial stuff!

Yours sincerely


Dr. Mark Pasola
General Practitioner in Kent
Lead Fundholding Partner
PCG Working Group member



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