Personal medical services

Pilot schemes for personal medical services are now in their fourth year. Rapid growth in their numbers means that 22% of England's general practitioners now choose to work in more than 1700 pilot schemes.¹ A national evaluation has recently reported on the progress of the first wave of pilots.² What evidence is there to justify health minister John Hutton's endorsement of personal medical services as “a proven success?”³

Pilots of personal medical services were brought into life by the NHS (Primary Care) Act 1997 and promptly endorsed by the incoming Blair administration. They are an antidote to the “one size fits all approach” of the national contract for general practice and a response to doctors' dissatisfaction with their traditional employment options.⁴

Yet the pilots amount to more than an alternative contractual framework—they have fundamentally changed the relation between government and general practice. Personal medical services entail local service contracts, negotiated between the provider and primary care trusts. They are subject to local targets, budgets, and monitoring. This leaves little room for national collective bargaining, and the General Practitioner Committee of the BMA has been disempowered as a result. Personal medical services break the monopoly of the independently contracted general practitioner. Now NHS trusts, primary care trusts, nurses, and, rarely, companies can contract to provide personal medical services. As a result, the number of salaried general practitioners employed has risen sharply. If independent contractors will not deliver local or national targets, primary care trusts can now call on alternative providers, at least in theory.

These are the political reasons why the Department of Health and ministers may be enthusiastic about personal medical services. Are there service related reasons why the pilots should be considered a proved success? Certainly, the process of recruiting salaried general practitioners has been as successful as would have been expected under general medical services in comparable areas. Employers of salaried general practitioners seem as satisfied with their staff as independent contractors are with a new partner. On average, salaried general practitioners are also notably cheaper than the independent contractors; they seem willing to trade income for better working conditions, such as freedom from responsibilities out of hours and paid sickness and educational leave. The evaluators conclude that salaried status leads to greater productivity with little or no impact on quality of care.

Pilots of personal medical services are also beginning to address longstanding inequities in primary care. They are increasing access to services and, in particular, serving population groups often poorly served by traditional general practice such as homeless people, refugees, and people with severe mental illness.

The pilots have also led to changes in the skill mix in primary care. Nursing roles in particular have been extended into new areas. At the most extreme, in “nurse led” pilots nurses have managed most first contact care and provided overall leadership in the primary care team.⁵,⁶

These developments are encouraging, and pilots of personal medical services have made substantial progress in meeting the most obvious deficits of general medical services. Yet there are some disappointments. The new cadre of salaried general practitioners may do little to increase the numbers of general practitioners overall. Most salaried general practitioners in the pilots have simply traded one post for another. Only 15% of the first wave of salaried general practitioners were new to general practice.⁷

The impact of personal medical services on quality of care is difficult to measure, and a clear “effect” is hard to detect. Practices offering personal medical services proved uncomfortably similar to practices offering general medical services across numerous domains. For example, the national evaluation that both types of practices made improvements to their management of chronic disease (with no difference between the two groups). Similarly, patients' assessments of quality of care remained remarkably consistent over the three year pilot period, with strikingly little difference between pilots and controls.

Overall, the evaluation team concluded that personal medical services, in some aspects of care, offers modest quality gains over and above those of general medical services—hardly a ringing endorsement. Furthermore, pilots of personal medical services received higher increases in funding over the period of the pilot (8.5%) compared with those received by the control practices offering general medical services (3.43%). Whether the modest quality gains represent value for money is an open question—and one that primary care trusts will have to answer.

Pilots of personal medical services, despite their local contract, also seem to have done little to alter the formal accountability of general practitioners. Little evidence of systematic management of pilots' performance through the contract has been detected. Although disappointing for managers, this might serve to reassure those critics who saw pilots of personal medical services as the route to United States style managed care. In this respect, the first wave of pilots was not typical. The Department of Health introduced a national contractual framework for third wave and future pilots.⁸

Ministers have confirmed their support for both personal medical services and conctracts for general medical services.³ But does the new contract for general medical services signal the end of the experiment with personal medical services? Certainly, the proposals for general medical services have borrowed many of the features of personal medical services pilots, not least the shift to a practice based contract. No doubt doctors offering personal medical services will look carefully at the pricing of the new contract for general medical services. It seems unlikely, however, that the Department of Health will allow personal medical services to wither on the vine, and local contracting is set to expand into community pharmacy later this year. After all, the government must feel its hand has been strengthened by the division in the ranks of general practice. It seems therefore that general practice will be faced with a choice of two contracts for some time to come.