Introduction

This chapter discusses how, some 40 years after Titmuss wrote the above, some of the last refuges of medical professional autonomy and individualism are being challenged. It describes the latest ‘framework of social resources’ – Primary Care Groups and Trusts (PCG/Ts) – and evaluates their prospects for success in, among other things, generating ‘better’ doctors (and nurses and other primary health professionals).

Historically, primary care – particularly the healthcare provided through general practitioners (GPs) – has constituted both the cornerstone and the Achilles heel of the National Health Service (NHS). Both as the provider of easily accessible, low cost, first contact and continuing care and as the gatekeeper to more expensive specialist health services, primary care has played a major role in ensuring universal healthcare is available in Great Britain, at relatively low cost. However, wide variations in the levels and standards of primary care services, difficulties in containing costs within a demand-led service, and the separation of primary care from mainstream NHS management and planning have together prevented the development of a service that is either of consistently high quality or integrated with other community-based health services. For the past 50 years, general practice has remained a ‘cottage industry’ on the fringes of the NHS, based on “individualistic, small shopkeeper principles” in which “the principles of free choice of doctors by patients and complete medical autonomy … remain sacrosanct” (Klein, 1983, p 14).

The creation of PCG/Ts arguably represents one of the most radical reforms of the NHS since its inception. This chapter describes the reasons behind these reforms and their implementation; assesses the implications and the potential for transforming primary and community health services; and highlights some of the risks and threats which lie ahead. In particular, the chapter will assess the contributions (actual and potential) of PCG/Ts to the ‘modernisation’ of the NHS. Broadly speaking, ‘modernisation’ is assumed here to refer to the high profile political objective of securing improvements in the delivery of public sector services.