Table Of ContentPRIMARY CARE DEVELOPMENT
Practitioners
and Practices
a conflict of values?
Julian Pratt
General Practitioner, Sheffield
Foreword by Professor Martin Roland
Department of General Practice, Manchester
Series Editors Pat Gordon and Diane Plamping
Published in association with King's Fund, London
CRC Press
Taylor & Francis Group
Boca Raton London New York
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First published 1995 by Radcliffe Publishing
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© 1995 Julian Pratt
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Contents
Series introduction vii
Foreword ix
Acknowledgements xi
Terminology xiii
Abbreviations
XV
1 Introduction 1
Summary of values 6
Conflicts of values 9
2 The core general practitioner: the doctor, the 11
patient and the illness
The context of development 11
The biomedical aspect 13
Biomedical physician as clinical generalist 15
Problems for the clinical generalist 17
iii
Practitioners and Practices
The biographical aspect 19
Problems for the biographical practitioner 22
The caring aspect 23
Problems for the carer 25
The healing aspect 25
The practitioner's core values 27
The practitioner 27
The values 30
3 Core general practice: the practice, its population 33
and their health
The context of development 34
Development of general practice by 34
general practitioners
Development of general practice and the 36
'new public management'
From 'the illness' to 'their health' 40
From 'his patient' to 'its population' 43
The population as all the patients 44
The population as an object of investigation 49
The population as an entity - the public 50
health
User and community participation 55
Community-orientated primary care 57
From 'the doctor' to 'the practice' 57
Is personal care compatible with 58
teamwork?
Boundaries with secondary care 62
Power 62
Ethical systems 64
Accountability 66
The general practice and its core values 70
The practice 70
The values 71
IIVV
Contents
4 Some possible futures 75
Changing roles within general practice 76
The disappearing generalist 79
Expectations of the patient 79
Expectations of the Treasury 80
Expectations of the practitioner 81
The health commission, its provider 81
organizations and contracting for health
Communities, their enablers and health for all 83
Practitioners and practices - conflicting values 85
Conclusion 89
References 91
Index 97
b
Series introduction
Primary care development is arguably the most important
topic for the NHS to get to grips with in the rapidly changing
environment of the 1990s. This new series of books about
primary care development is intended to be topical, useful
and, before very long, out-of-date. It is based on the current
work of the King's Fund Primary Care Group and the ideas,
experience and inspiration of a number of people who have
worked with us and shared their enthusiasms.
Primary care is often used to mean general practice. Here
it is used to mean the broader network of community-based
health services which in the UK allow us to manage 90% of care
outside hospitals; to manage earlier, safer discharge from
hospitals, and to maintain people at home who do not want to
be institutionalized.
From a position of relative neglect and invisibility, primary
care has shot to the top of the NHS policy agenda. This has
much to do with the NHS reforms and the drive to control
public spending. Like all industrialized nations faced with
ever-increasing costs in health care, we are experimenting with
reorganization. Since hospitals use most NHS resources, this
is where most attention was directed and primary care became
the focus only as a potentially cheaper option. But the drive
for efficiency and value for money coincides with other power-
ful influences which challenge us to examine alternatives to
VII
Practitioners and Practices
traditional ways of delivering services. If effective primary care
really is the key to successful health services in the future, then
recognizing its distinctive characteristics, and what we value
about it as well as what we want to change becomes critical. In
other words, primary care has development needs in its own
right quite apart from the current emphasis on the shift from
secondary to primary care - the so-called substitution agenda.
This new series is about ideas and services which are being
developed and tested around the country. It is about work-in-
progress in a period of extraordinary change. It is about
general practice as well as general practitioners; about develop-
ing new kinds of primary care organizations; about the capacity
to deliver high-quality nursing care at home; and about poly-
clinics and resource centres, specialists and generalists. The
series begins, appropriately, with Julian Pratt's book on
general practice. The underlying model of general practice is
being challenged by new ideas of the role of the practitioner
and the organization in which she works. Forthcoming titles
address practice management, the fastest growing health care
occupation in the UK, and new ways of extending primary care
beyond family-based practice to polyclinics and hospitals at
home. We hope the ideas in these books contribute to the
debate about the future shape of the NHS and are useful to
the people working in the middle of these major changes now.
Pat Gordon
King's Fund
London
February 1995
VIII
Foreword
The pace of change in the NHS is so great that many within
primary care wonder whether the core values of general prac-
tice, which have led to Britain leading the way in the world
in primary health care, can survive without being damaged
beyond recognition. This book takes a unique analytical
approach. Julian Pratt has drawn on three conferences organ-
ized by the King's Fund which were designed to see how the
core of general practice could be maintained and
strengthened in a changing world.
Dr Pratt identifies those values which are central to the
practitioner for whom a one-to-one relationship with her
patient is paramount. He contrasts these with the 'practice
values' which are needed by a range of health professionals
whose focus is how to maximize the health of a practice
population within available resources. He addresses the inevi-
table conflicts between trying to accommodate both sets of
values within one practice organization. He argues that
patients will lose out if either set of values seeks to dominate.
Practices need to acknowledge that a constructive tension can
exist between the two approaches, and that practitioners and
practices need to find ways of building on both sets of values
in order to realize the full potential of primary health care.
Many feel currently that if general practice as we know it
survives, it will do so in spite of the organizational changes
IX
