The fragmentation of primary care provision will present huge challenges to GPs providing and commissioning services over the next decade, according to key opinion leaders in the NHS.
This was the overriding theme of a debate hosted in London last month by the National Association of Primary Care. Some of the most influential people in the sector gathered to discuss the future of general practice, and how it would look at the completion of the NHS plan in 2010.
Dr Rebecca Rosen, policy adviser at the King's Fund think tank, and a part-time GP, warned that trying to meet the varied needs of different patients would have knock-on effects across the whole healthcare system.
'It's incredibly important to recognise the fragmentation that we are going to have to work with in primary care, for example when young people come in for a quick fix and then carry on,' she said.
'Responding to the convenience side of minor ailments will stoke demand. The more we try to meet that demand means less resources for other services.
'So we have to be clear about the parameters, given the current purse strings. And we have to think about having lots of different players responding to different needs but keeping it coherent, and continuing with public health measures.'
RCGP chairman Dr Mayur Lakhani asked whether patient choice was compatible with the current values of general practice and registered lists.
'I think it is,' he said. But we have to show that we can deliver what patients need. It's paternalism if we say we know what's best, and paternalism is dead.'
But Dr Richard Fieldhouse, chief executive officer of the National Association of Sessional GPs, said there was still a place for paternalism.
'We try to offer patients choice but they do not want it. We should not abuse paternal care but we need to be able to use it when necessary,' he said.
Former chairman of the GPC Dr John Chisholm said the importance of continuity of care depended on the patient and their circumstances: 'There are circumstances where people choose continuity of care but for healthy young adults it is often not important.'
Decline in continuity
He also suggested that general practice had contributed to the decline in continuity for patients: 'The profession, in its move to part-time working and the transfer of out-of-hours responsibility, is itself reducing continuity of care. People are on a practice list now and only focus on a particular professional when necessary.
'Unless we are going to become much better at listening to what our patients want and need, we are going to fail at practice level and practice-based commissioning.'
Dr Michael Shillingford, medical director of the Medical Property Fund, said current changes in the NHS were offering an enormous opportunity for primary care to improve, but also to 'screw things up'.
'We should be delivering a lot more through the web and new technology,' he said.
He warned that GPs could become isolated, as new and existing providers took the initiative in the primary care market: 'Should it be GPs who see patients first, or nurses or someone else? Pharmacists, for example, should be providing 20 to 25 per cent of care for patients. They are very much part of the same care pathway.'
One senior manager said a major threat could come from secondary care: 'There is a lot of interest from large acute hospitals in owning primary care. That seems to be a powerful driver at the moment.'
But the main threat to the future of general practice services, according to a DoH policy adviser, was the 'lack of aspiration for patients', rather than a lack of experience in operating at a strategic level.
'We need to have a much higher level of aspiration and then see how to deliver it,' he said. 'Budget restraints are then not so relevant because it's less expensive when we do things better'.