Family doctors are to lose their monopoly as frontline providers of health care in a radical extension of patient choice in the NHS, ministers revealed yesterday.

Private companies employing their own doctors and medical staff will be encouraged to compete with traditional GP surgeries in a drive to end the one-size-fits-all NHS.

Patients could soon be offered speedier, more convenient treatment by nurse-led clinics, and pharmacists will attend to minor ailments and write repeat prescriptions.

New services will offer regular monitoring for people with chronic illnesses, such as asthma and diabetes, and independent companies will be invited to run fast-track diagnostic testing centres in the community to speed provision of blood tests, X-rays and endoscopies.

The White Paper, Building on the Best, was launched by the Prime Minister, who has made the extension of choice in public services into a personal crusade. Tony Blair said the three-month consultation with organisations representing 110,000 people had provoked the "biggest response back on virtually anything we have done in the health service".

The White Paper extends measures already being implemented to give hospital patients choice into new areas, including primary care, maternity and children's services and the care of the terminally ill.

John Reid, the Health Secretary, said the health service had to refocus from collective to individual needs if it was to survive the next 50 years. He said: "The overall aim of our reforms is to turn the NHS from a top-down monolith into a responsive service that gives the patient the best possible experience. We need to develop an NHS that is both fair to all of us and personal to each of us."

A choice of hospital is already offered to some patients waiting six months for operations, and figures published last week show 70 per cent of heart patients and 48 per cent of cataract patients have taken up the offer. The same choice is to be extended to all patients waiting at least six months by August next year, and, by December 2005, every patient is expected to be able to choose from four or five hospitals at the point of referral.

In primary care, different people want different things, the White Paper says. Older people and those with chronic illnesses prefer the traditional GP, while younger people value being able to get quick help at a convenient time and place.

But 15 per cent of the population live in areas where practice lists are closed to new patients, the White Paper says. To meet these differing needs, primary care trusts will "test new ways to encourage new entrants" to the field from April.

One option is for companies running out-of-hours services, which provide night cover for GPs, to move into daytime services, with walk-in centres, as well as the traditional home-visiting service.

The NHS Confederation, representing NHS managers, welcomed the proposals but warned they required a "fundamental culture change in the relationship between patients and professionals".

The British Medical Association responded cautiously, praising the "imaginative initiatives" to make more use of pharmacists to ease the burden on doctors but warning that some of the proposals "raise a number of questions which we look forward to discussing with patients and government at the earliest opportunity".

Analysis: Reid's aim: a flexible and responsive NHS

One sentence stands out from the British Social Attitudes survey published this week. Although backing for the NHS remains as high as it has ever been, it is now conditional. "It cannot rely on support for its founding principles; the care it delivers must not only continue to improve but, crucially, be seen to do so."

The message is that increased investment and improving standards of care will not, alone, be enough to sustain political support for the NHS. Despite the huge injection of funds into the service in recent years, the number who say they are satisfied has fallen from 46 per cent in 1999 to 40 per cent today.

Satisfaction depends not only on lives saved and disease cured but on the NHS's capacity to meet public expectations honed by people's ordinary experiences in dealing with banks, supermarkets and commercial services where consumer choice reigns supreme.

John Reid, the Health Secretary, has championed choice as the mechanism that can drive change in the NHS from the earliest weeks after his appointment last June. The Tories had the internal market and competition between NHS trusts, and Labour in its first term had performance management and star ratings. For Mr Reid, patient choice is the new grit in the oyster that will replace the market and star ratings to deliver a more flexible, responsive, locally sensitive health service.

Critics maintain that choice is irrelevant to most patients who all want the same thing - quick service of a high standard at their local hospital. But as yesterday's White Paper shows, there are other choices to be made that will suit different patients with different needs.

Some want quick access to a minor ailments clinic while others want continuity of care from a GP personally known to them. Within the NHS's limited capacity, there are ways in which the one-size-fits-all service can be segmented to suit the needs of its varied clientele.

As Mr Reid is fond of observing, offering choice to NHS patients merely equalises their position with the privately insured who have always enjoyed the freedom to select their consultant, hospital and time of appointment.

The social solidarity that has sustained the NHS during the past 50 years was based on the collective values of a universal service, available to all who needed it, free at the point of use. To sustain it through the next 50 years it will have to adapt to the individual values driven by consumer choice that dominate modern lifestyles, or it may wither and die.

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