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CAMHS won't see you now

Family puts target pay in jeopardy over vaccines

Three GPs debate a current controversy

Case history

Supported by her mother, with whom she lives, Clare has steadfastly refused to allow her five-year-old son Jake to have any immunisations. Clare's mother asserts that the entire family does not believe in immunisation and none of them has suffered as a result, despite the fact that Clare and her two teenage brothers all have special educational needs. One more unimmunised child would mean you miss your targets.

In reception you overhear a conversation between Clare's mother and the receptionist. Clare's sister has returned to the parental home with her six children aged between five months and six years. They plan to seek rehousing locally and would like to register with the practice. The entire family books appointments to see you this week.

Dr Harry Brown

'They should not be turned away just for declining immunisation'

If I was on the borderline for higher targets, we would already be aware that we risk losing this income stream. If a target is met then that is fine. A near-miss can have financial consequences, but it is important not to lose sight of the greater ethical duty you have to the patient.

If this new family are going to object to immunisations and will not be persuaded, then so be it. Under no circumstances should they be removed from the list or turned away simply on the basis that they have declined an immunisation, which would adversely affect the practice target status. However, I would not meekly surrender but try to convince them of the merits of immunisation.

I would wait until they appear for their routine appointment and, unless it has already been covered, ask the mother about their immunisation status. They may be fully immunised or prepared to complete the immunisation schedule. If she objects then I'd need to find out the nature of their objection without being judgmental or attempting to pressurise them. If after a discussion it is plainly obvious that the mother will object and does not want immunisations then I'd accept it, discuss it with the health visitor and arrange follow-up.

If after follow-up (or if they default) they still have not been fully immunised then I'd note it in the records and when they present for another reason I would discuss the topic again. But if the mother still does not want immunisations, there is little else to be done.

Why have other children within the target group not been immunised? Is it worth seeking them out and persuading the parents to comply with the missing vaccinations? Perhaps the target can be made up by this route.

At the end of the day, general practice is a tightly regulated business just like any small enterprise and income streams come and go. Under no circumstances should financial considerations interfere with any doctor-patient relationship.

General practice is all about taking the rough with smooth.

Dr Nick Jones

'We have to give the family the best medicine they will allow us to'

Hey ho, the list is dead, the wicked list, the wicked list, hey ho, the wicked list is dead. Though unfortunately not closed. Rats. However much we look to ourselves as individual practitioners (and we should more often) we are still employees of the state.

Anyone who disagrees should try not meeting a quota then asking for the money 'as we worked bloody hard to get as many immunisations as we did'. They don't get their percentage and you don't get yours.

Unfortunately, when the people paying the piper don't know what tune they want, how long they want you to play it for, and then ask for a tune that is five years out of date (God forbid you are a solo piper!) they still get to call the tune.

To finish my Snow White analogy, we may be a little more worldly wise but we're still all good little apple eaters. It's what we do. And if we want our jobs and not to have solicitors haranguing us, or have bricks through the window (or maybe even solicitors through the window) we have to treat them as human beings and give them the best medicine that they will allow us to.

The only saving grace in all of this is in the fine detail: they are planning to move into the area. 'Terribly sorry, but we are unable to let you join the practice until we have confirmed your status. We'd be happy to take you as temporary residents should you have any immediate medical needs.'

'And if housing is anything like it normally is, look forward to a long wait, a lot of letters and a long drive to the place furthest from where you requested to be.'

As a side note, this has made me think of just one thing. When our Government is run by itself, for itself and driven by headlines, how long before all immunisations are optional? After all, if one injection can cause autistic bowels what might others be doing?

Next step, private immunisations (flu jab at Asda, anyone?), and another headache off the Government's mind. Free will is a wonderful thing. So they tell me.

Dr Jane Willoughby

'Reasoning has had little effect

so to an extent I am powerless'

This is a frustrating situation, which will no doubt have me cursing the family and the immunisation target payments. Reasoning with the family has clearly had little effect in the past, so to an extent I am powerless.

It appears that Clare is not able to make decisions for herself regarding Jake's health and this probably extends to other areas of his care. I would want to discuss the set-up with the health visitor to ensure Jake is being cared for adequately and there is no risk of neglect. The family may benefit from social support.

The issue of whether Clare is competent to deny Jake vaccinations is very grey and this is where some social work input may be helpful. It isn't clear whether Clare's mother is competent to decide either (I would be suspicious about her mental status if so many children are impaired) but she certainly isn't Jake's legal guardian!

I will be reluctant to take on another arm of this family, but it would not be ethically possible to deny them a place on the list because of the immunisation problem. Initially I would take them as temporary residents until they are rehoused ­ with luck this may be outside my area or our list may be closed.

I would not see the whole family unless they have a current medical need but would like to meet Clare's sister (without her mother) to check out the situation ­ she may have had her children immunised.

More seriously, I would want to establish whether she has had a learning disability when considering the health of her children. The health visitor needs to be informed of the new arrivals. In these circumstances your motives for pursuing families are always clouded by the target payments ­ the sooner these targets go the better, I think they are completely unethical.

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