“If you take it to its logical conclusion, the Secretary of State will have to define exactly what primary care does – forever,” said the GP on the other end of the line.

We were, of course, talking about the white paper. This GP has been at the forefront of redesigning services, leading colleagues into territory they have not traditionally inhabited.  Their concern was prompted by the implication, inherent in the white paper, that the conflict between being a commissioner and a provider will require freezing, or fossilising general practice in its current form.

If, as an unintended consequence of the reforms, general practice is fixed in its current form then, I believe, that will be a poor outcome.  The Royal College of General Practitioners published a road map to The Future Direction of General Practice three years ago. On page 33 there is a diagram of volume and complexity in health care, which they use to illustrate the shift in polypathology GP teams need to deal with.  Looking at that it struck me that over the last twenty years the line separating GP work and specialist interventions has shifted. Twenty years ago patients needed to be despatched to the local DGH for access to diagnostics and “specialist” advice.  That threshold has, or should, have moved over the last twenty years.  More and more can, and should, be done in an “out of hospital” setting.  Yet the BMA General Practitioners Commitee (GPC), and now the Secretary of State, seem determined to fix, freeze, and ultimately fossilise General Practice as a form of provision, which was great for most of the twentieth century but is floundering in the face of the demands placed on twenty first century health care.

The white paper presents a huge opportunity, a turning point for the NHS.  British general practice is internationally recognised to be of high quality.  Over the decades it has adapted and evolved to meet and address changes in health care. Right now is the time to stimulate it to evolve rapidly to address the “climate change” we face due to demographics, diseases, and economics.  One of the key questions the new, yet to emerge, system will have to resolve is the difficulty GP led commissioning will have in fostering that evolution. The potential is there – can it be realised?

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.