Hi Kate - can't disagree with you at all and I for one wish Unison success but I doubt that they will find any. For interest here is the slightly modified text of a response I wrote on this subject on a previous Doc2Doc thread a few weeks ago (I have since sent similar views to the BMA and RCGP and I think that the BMA in England and the RCGP have both been far too sedent in their responses to this Paper):- I think it's fair to say that the responses I have seen to this White Paper from colleagues in Scotland imply that it would be a disaster for Primary Care here. I think we have to recognise that the NHS in England and Scotland, particularly at the level of primary care, are now so far apart as to effectively be two separate institutions. Primary care in Scotland is still glued together by a strong sense of public service and egalitarianism. Money and the business model of general practice are (and always have been) of much more secondary importance to GPs in Scotland - which probably explains why we continue to tolerate earnings which are, on average, nearly 20% less than our colleagues in England! But as to the general point about being involved in health policy decision and feeling empowered I think we could be better off but that applies to almost every front-line service in the NHS. The current management structure is not as good as it could be but the fundamental problem, in my view, does not require radical change as it is simply down to poorer communication than we used to have and a more centralised, top-down approach to management. My original criticism of the English White Paper still holds. Firstly, let me say that I believe that most doctors do not make good managers. That belief is based on 20 years of experience of Trusts, LHCCs, medical directors, clinical directors, etc. Most have had no formal management training and even within GP land most have now handed over day to day management to a Practice Manager. I know that this White Paper is not intended to be Fundholding mark 2 but let's not beat about the bush - in my view Fundholding Mark 1 sucked and there are enough hints in this paper to worry me that we may end up with something along the lines of Fundholding Plus. Some GPs are not really altruistic when it comes to the crunch and fundholding demonstrated that in the raw. There were a lot of GPs and a lot of practices quite happy to do things under fundholding knowing that they were under-mining their colleagues and neighbouring practices in the process. The resentments of those days are still evident in my part of the world today. I have seen nothing that convinces me GPs will make good commissioners. GPs are not good at looking at the bigger picture - secondary care has little idea of what goes on in primary care but the reverse is also true. In my view, at a macro-level, health policy should be determined by politicians and civil servants in discussion with the BMA and Royal Colleges. That's what appears to be happening superficially at least with this White Paper and that's fine as far as it goes. In GP land the two big issues remain QOF (quality and outcomes framework) and enhanced services. QOF should be determined at a macro-level as above - and remember it was doctors who gave us the more controversial aspects of QOF (such as chronic kidney disease). The only role I see for GPs is at the micro-level - this happens already, to a greater or lesser extent, with enhanced services (although I do see a bigger role for LMCs in that respect). But what other role do we perceive GPs having? Do we really want GPs to decide if the new community physio is employed for 13.5 or 17.5 hours per week or whether the community nurses should be resticted to one pack of incontinence pads per week or whether Zoladex should be removed from the local formulary or whether there should be four or six out reach Ophthalmology clinics per year? Such is the stuff of management and I for one want no part of it thank you very much! QOF and enhanced services and the tick box bureaucracy that goes with them have already impinged significantly on doctor-patient contact time. How would taking on more management responsibilities improve that situation?