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Danger lies ahead in contract-led agenda

One of my partners told me that in one of her consultations the other day she was about to inquire into the smoking habits of one of her patients when the patient tearfully began to tell her about a recent family tragedy ­ clearly the reason for her attendance.

The doctor abandoned her own agenda in favour of that of the patient. So: no points for failing to achieve aspiration criteria, but maximum points for wisdom and sensitivity.

Which brings me to one of the reasons why I voted against the new contract. Initially my gut instinct was that anything so ornate must be fundamentally flawed. On the one hand, since much of the required behaviour will be income-driven it will require an army of people to verify and monitor performance, people who may have little understanding of the doctor-patient relationship nor of the complexities of the consultation.

On the other hand there is no doubt that for many of us the contract offers clinical, organisational and information-management challenges. The honest achievement of some of the 'aspirations' (which are based on good clinical care) is likely to improve overall care of patients with diabetes, hypertension and IHD.

From an epidemiological viewpoint this may be true, but it is questionable whether the individual patient will see the upsurge of information-gathering as an improvement. Why?

Many patients do not understand risk groups, statistical probability and so forth.

Most of all, they want time for the doctor to listen and respond appropriately to the things that are troubling them as individuals. I am not suggesting we should adopt an

approach of benign neglect ­ I am pointing out the risks of slavish adherence to the demands of the contract.

For years we have been taught about the importance of patient-centred care, one of the cornerstones of an effective consultation. The contract may make the doctor's agenda so all-pervading that there is a danger we will regress into a strongly doctor-centred approach, driven by time constraints and 'points mean prizes.'

Many patients will find this exasperating, if not odious.

Dr Rod Manton

Marple, Cheshire

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