Rural practices have long felt ignored by policy makers. But a string of recent initiatives have strengthened the feeling that the DoH is putting together plans designed to appeal to the suburbs, with scant regard for the impact they will have on other areas.
Take Lord Darzi's plan for a polyclinic in every PCT as an example. GPs say this makes sense in densely populated areas struggling to attract GPs. But in less populated areas it's a different story.
'In Bradford, there is a need for a new practice,' said Dr John Givans, secretary of two Yorkshire LMCs. 'But it's very difficult to think of anywhere in North Yorkshire where it's in the least appropriate. Many GPs think that the prime minister just wants to please commuters in the home counties.'
Indeed, some believe polyclinics could actually be damaging to primary care. For one thing, they cost money, which then can't be spent on existing services. Secondly, they could destabilise neighbouring practices by poaching their patients.
Dr Brian Balmer, the chief executive officer of Essex LMC, said this is a 'major concern all over the country', and warned that practice viability could be affected.
Perhaps an even bigger issue is the debate over extended hours. Some GPs accept that the policy makes sense in areas where patients spend an hour or more commuting and struggle to get appointments. But many rural GPs are angry that they are being expected to provide services for which there is no demand.
Dr Susan Taylor, a GP in the western Highlands and chairwoman of the Remote Practitioners Association, said that she already offers evening appointments and out-of-hours care, where patients demand it.
'I'd hoped that being able to demonstrate that flexibility would be enough,' she said. 'Services should be patient-led.'
Nonetheless, she is facing a choice between spending three hours a week in an empty surgery, or taking a funding cut.
Like polyclinics, there is an opportunity cost in extended hours. Cumbria PCT wants to reduce referrals to secondary care, in the hope of preventing a repeat of the £50 million deficit it spent last year struggling with. Yet the GMS contract changes will force it to focus on improving access - despite receiving a 90 per cent score in recent patient satisfaction surveys.
'Why the hell are they giving us metropolitan solutions in Cumbria?' asked Dr Colin Patterson, North Cumbria LMC chairman. 'They're telling us to fix a problem we don't have.'
These problems are not unique to rural practices: some urban practices are also finding that the one-size-fits-all diktats do not fit their needs.
But rural practices are often most vulnerable to financial shocks, with more dispersed populations meaning higher costs. They are dependent on the slowly eroding MPIG to survive.
According to Dr Patterson: 'A lot of rural practice is marginal. If they suck money out, our PCT is going to have to find ways of giving it back.'
Unless a compromise can be found, many rural practices will lose out under the contract changes - with or without extended hours. Dr Taylor said the deal leaves her with no option but to take a pay cut. Her list is so small that, even if she offers extended hours, the extra income generated is unlikely to cover the extra staff and energy costs it involves.
'If the (Scottish Executive) can accept a local agreement that assures health boards that patients are getting the care that they need, that would be acceptable. But if I have to follow the guidelines being offered in England, I will lose money.'
Dr Peter Holden, a GPC negotiator, shares these concerns, and fears longer hours will make it harder for rural practices such as his own to attract staff. But he said there are no answers to these problems yet: 'First we've got to wait and see what the poll says.'
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