Dorrell must decide what he wants from doctors

It is unrealistic to expect GPs to be both managers and clinicians, writes Alan Maynard

Just what do we want in primary care? Government policy is incoherent and the profession, represented by the strongest of trade unions, the British Medical Association, doesn't know whether it is coming or going.

The Government likes the idea of general practice fundholding. It has given generous budgets to successive waves of fundholders, resulting in over 50 per cent of the population being covered by them. This massive experiment has not been evaluated: Kenneth Clarke, then the Secretary of State for Health, rejected evaluation as unnecessary because, like his colleague, Mrs Thatcher, he did not wish to be "confused by facts". As a result, the lessons of fundholding are difficult to learn. Initial studies showed that fundholders appeared to prescribe less in the early years. However, more recent follow-up shows that these effects have disappeared and fundholders are similar to non-fundholders in drug expenditure.

For effective fundholding, management must be excellent to ensure vigorous and cost-effective purchasing of hospital services. However, GPs have been trained as generalists, the "gatekeepers" who treat 95 per cent of illness in the community and, on a good day, restrict over-use of hospitals. GPs have not been trained as managers of complex fundholding organisations working to restricted budgets in a competitive environment.

It is on this managerial weakness that next week's Audit Commission report will, according to leaks, focus. Fundholding has reversed power relationships. As the joke goes, GPs used to send consultants Christmas cards to get their patients up the waiting list. Now hospital consultants send GP fundholders Christmas cards to ensure they get business.

Fundholders, particularly the initial waves, were well funded and NHS trusts, strapped for cash, give precedence to the patients of fundholders. This has been covert in some areas, but, in the lightly funded NHS of 1996-97, it will become much clearer: cash will produce care. This differential access to hospital care is replacing the access inequalities of the pre- reform NHS where consultants called the tune and decided - according to disparate, incoherent and unaccountable criteria - who got access.

While the Government wants GPs to be managers, they also want them to become semi-specialists. Politicians of all parties advocate a "primary care-led NHS". This notion is vague and relatively untouched by human thought, let alone evidence. Draft NHS circulars envisage many hospital procedures being moved out into the community and primary care.

This movement will be expedited by money: as Kenneth Clarke noted during the NHS reform process, if you rattle the GPs' wallets, they are very attentive. The 1990 GP contract offered fees for minor surgery to cut down hospital "lumps and bumps" work. That work has continued, but GPs now do lots of surgery (for money) which is sometimes deficient (eg, the partial removal of cancerous lumps is not good practice).

If local NHS purchasers are to pay GPs fees for more hospital work, can quality be maintained? Quality can only be achieved if GPs and nurse practitioners are well trained and well managed. Again, management is central. The management costs of the NHS are relatively modest and the quality of management remains uneven. The Secretary of State for Health, Stephen Dorrell, in his reduction of expenditure on "grey suits", ensures that the management of an NHS budget of pounds 40bn is inadequate.

The paradox of primary care is that everyone loves it but no one evaluates it and the Government is confused in its policies. Does it want GPs to be managers? If so, they need training, in which case the question is: who will do their clinical work? Does the Government want GPs to be semi- specialists rather than generalists? If so, please train them and manage them and their support staff so that they do not damage patient health.

Perhaps the appropriate role for GPs should be as the generalist filter of the chaff of human suffering, whose job it is to identify the rare acute form of illness in their populations and transfer them rapidly to secondary care. Whatever their tasks, it is necessary to monitor and evaluate primary care so that policies like fundholding produce knowledge to facilitate our avoidance of the charms of the next untested panacea adopted by politicians.

The writer is secretary of the Nuffield Provincial Hospitals Trust for research and policy studies in health services.