GP reforms to revive cottage hospital care

The most radical changes in 50 years to the way family doctor services are organised and delivered were trailed yesterday by Stephen Dorrell, the Secretary of State for Health.

They could mean the revival and development of new-style "cottage hospitals" with X-ray, diagnostics, day surgery and respite beds which could provide a wide range of additional services from physiotherapy and pharmacy to mental health and care for the elderly. Private finance is likely to be used to develop them. Over time, nurses and others would be likely to gain more prescribing rights.

More GPs could be salaried, working for community trusts or partnerships, rather than operating as at present as independent contractors. Some could split their contract between day and night services, ending the traditional 24-hour responsibility of GPs for their patients.

The traditional boundary between money for hospital and community services and that for primary care could go, with health care being funded from a single budget. That would make easier the transfer of new technologies and resources out of hospitals and into primary care - and might eventually lead to a Treasury ambition of a single, cash-limited budget for all forms of care.

In places the national GP contract could be replaced by one negotiated locally with health authorities. And the existing and complex way in which GPs are funded might go in favour of a formula for distributing the cash more fairly.

The potential transformation from the one, single national GPs contract which has existed since 1948 to a much more varied pattern in the way care is provided was outlined yesterday by Mr Dorrell in a document headed Primary Care: The Future. It marked, Mr Dorrell said, "a very important day in the history of the NHS".

It trails a clutch of ideas for redeveloping general practice and its associated services in a way that is likely to see them run in differing ways to suit local needs, varying between different parts of the country.

In stark contrast to the introduction of the NHS reforms in 1991, Mr Dorrell promised that a firmer "agenda for action" would be set in the autumn and then piloted to establish which changes work. The changes would be undertaken, he said, on a voluntary basis, going ahead only where there was "professional support" for testing them and "without removing the option of continuing to practice within the current arrangements".

Mr Dorrell's approach lets him escape negotiating a new contract with the increasingly restless GPs this side of the general election. Should Labour win, it also avoids binding them to a rigid set of changes.

The GPs' traditional role as "gatekeeper" to the rest of the NHS must remain, the document says. Services must be developed against principles of quality, fairness, accessibility, responsiveness and efficiency, including clinical effectiveness. The aim is to "keep the traditional strengths of general practice" while allowing "more flexibility and greater choice" in the way services are delivered, particularly given the unacceptable variation in how well primary care is delivered around the country.

The shift from imposing changes to piloting and negotiating them was welcomed by the British Medical Association and health authorities. Dr Ian Bogle, the BMA's GPs' chairman, said he was glad ministers had listened to family doctors' worries about growing workload, unnecessary bureaucracy and worsening morale and recruitment problems. Any changes, however, would have to be "adequately resourced".

9 Primary Care: The Future, NHS Executive. Copies from 0800 555777.