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Alcohol dependent patient keeps attending as an 'urgent extra'

Last week Dr Nev Bradley lambasted GP leaders for refusing to define core services ­ GPC chair

Dr Hamish Meldrum responds

The motion proposed by Dr Bradley and passed at this year's LMC conference basically asked for three things:

·Define core, non-core and enhanced services

·Advise practices what to do and how to say No to non-core services

·State it's the GPC strategy to protect primary care enhanced services after the Government's sudden introduction of the partial sale of goodwill.

Dr Bradley says good unions lead from the front. We agree. We might add that a union is only as strong as the members are prepared to be, but that is a different discussion! Leading from the front does not always mean taking the easy way, or indeed the most popular. It means doing those things that will most benefit the profession and taking into consideration all the relevant issues, including taking appropriate legal advice about the guidance we release.

The whole purpose of the enhanced service strategy was either to bring resources into the practice for the 'flypaper' work he mentions or to allow GPs to be able to decline the work and allow the PCO, or whoever, to find another provider of those services. He then lists the work his LMC did in trying to define core and non-core service. His list includes some 30 items but he admits it is not exclusive. We would agree. The list could run into hundreds of individual items and even then we might not catch all the things that trouble GPs.

His list includes things that are already clearly non-core because they always have been private work that attracts a fee, such as gym and insurance medicals and Section 12 work. Do we really need to be told that these are not part of our GMS contract and that they attract a separate fee?

He includes things that have always been part of a GP's contractual work in the past even if we hate them, for example sicknotes and private referrals. He includes things that are currently being talked about but which the GPC has already made clear are not part of the core work of a GP, such as copying letters to patients.

He also includes areas of clinical work that some GPs would see as part of their general practitioner role. This is the most difficult part: to get 40,000 GPs to agree. For example, some might feel helping patients to stop smoking or lose weight is part of our health promotion role. Others might feel ear syringing is part of our practice nurse work, not just the work of the district nurses. He mentions the 'difficulty' the members of his LMC had in reaching a consensus on even these 30 items. Imagine how difficult it would be to get 40,000 GPs to agree a list that could be almost infinitely longer.

What would we do about those items that we could not agree?

We already know those things that are non-core because they are private. We already know the things that are clearly enhanced services because they are currently designated as such. These would include warfarin and secondary care drugs monitoring, more specialised alcohol and substance misuse services, and so on.

We have been trying to set up a 'library' of local enhanced services that LMCs have been successful in agreeing locally, but even after many requests to have these sent into the GPC office, our list remains pitifully low, even though we know that LMCs have been able to agree a whole range of LESs.

The ones we know of include asylum seekers, nursing homes, modified drug misuse schemes, 'practice treatment room' payments, suture removal, and payment for Depo and implant contraception. There are others under discussion at the moment such as Zoladex and related injections.

This is the problem we face in trying to categorise everything we do. Then there are those GPs who genuinely feel that even this start we have made will damage general practice and lead to its eventual downfall. Being a leader means trying to consider all view points and all concerns raised, not just certain ones.

We have already published a 'Focus on' document on how to say No to non-core work. This is available from the GPC website and was sent to all LMCs months ago. Anyone not sure of the steps they need to take to remove themselves from the future provision of these services should read it immediately.

As to the sale of goodwill, this too had mixed responses from GPs. Some thought it to be a serious danger to the profession while others thought it would be a boon to those willing to provide a wider range of services, outside core services.

We cannot send out any guidance on this until we have seen the regulations. We then have to get legal advice on the consequences of the sale of goodwill and how it can be used to protect and/or benefit GPs. So even though something is asked for in June, it can not always be delivered in August simply due to the time it takes with some of these very complex regulatory and legal issues.

GPs are beginning to be paid for work they have been doing but never paid for in the past. Many GPs are now seeing income for INR monitoring and drug misuse work because of the enhanced service strategy and a lot of hard work done by LMCs.

Other GPs have been able to stop doing work they have no wish to continue doing even if they were paid, like minor injuries. The other main gain that we may not see or appreciate now is that we will have become expert in saying No to work or in refusing to do it for no additional resources.

This is already resulting in new work being refused, or not even being sent to us in the first place as the PCO and even some Government departments now know they can no longer dump work on us in the way they used to. They either have to pay us or get someone else to do the work.

We are not ignoring the conference resolution. We are trying to implement it in a practical and legally acceptable way. That is what leadership is all about.

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