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At the heart of general practice since 1960

GPs' views: Influx from neighbour risks deluging our practice

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case history

You are being deluged by requests from people to join your list from a neighbouring practice which has always had a good reputation. The partners there are an entrepreneurial bunch and have taken on lucrative outside corporate work.

One of them has confided in you that they earn treble what they do in general practice. General practice is their fallback in case the corporate work dries up. A high level of dissatisfaction is evident among your new patients. As the records filter through, it's obvious the standard and quality of medicine at the neighbouring practice leaves a lot to be desired.However, your practice is in danger of being swamped by the increasing number of new registrants. What should you do?

Dr Harry Brown 'If there is no action by the PCT or the neighbour, we could close our list'

My first response would be to monitor the rise in new patients ­ is the practice growing too quickly? Or are the workings of the practice being slowed down by the fact that the new patients need a lot of work?

Equally, I would recognise that doctors in the neighbouring practice are earning significantly more than me and my partners, and I would try to put aside any personal feelings of jealousy, anger or resentment. If indeed there is a significant rise in new registrants all coming from the same practice, and if there are signs of deficiencies in their care when they arrive, then the onus is on our practice to take some action.

My first port of call would be to the neighbouring practice, which is the source of the problem. I would arrange a face-to-face meeting, and would bring our partners and practice manager. A full and frank discussion should be the order of the day, and I would bring data and examples with us.This could include the numbers of patients joining our practice, and examples of poor medicine we have come across.

I would point out we are not getting at the neighbouring practice and don't want to make waves, or report it to an authority such as the PCT. The neighbouring practice may be aware its list size is declining and that there must be good reasons for this. It is not our role to solve their problems. The reception we get, and the action it promises, will determine what happens next. If they seem keen to make changes that will improve the service offered to their patients, then we should hold fire.

We would hope these measures would stem the flow of patients to us. If they are dismissive and not interested, or if after some time nothing has changed, then we would contemplate taking further action. The next port of call could be a senior official at the local PCT. He/she may well be aware of the situation.However, we are looking for action. If there is no positive action from the PCT or the neighbouring practice, then the next potential response could be to close our list.

Harry Brown is a GP in Leeds and a trainer

Dr Joanne Harris'Such a large migration would alert the primary care organisation'

This could harm the neighbouring practice financially in two ways. It could be penalised on the annual quality and outcomes framework visit when it is found to be not matching up to the points total it aspired to.

One of these targets involves a patient satisfaction survey to be discussed with the primary care organisation. One can only imagine how badly it might score in this area. The second way it could be penalised is the loss of patients, which would lead to a reduction in its global sum and so less money to pay all those locums and assistants.

The practice may argue its corporate work is so lucrative that it doesn't need to worry about the NHS income. But this is extremely shortsighted since the corporate work can be fickle and the company may find itself another provider, so putting the practice out of business. When the corporate work dries up, the practice may find that the NHS work is no longer there as a fallback.

Another part to this dilemma is how it is affecting my own practice, which is being deluged with many disaffected new patients. Many practices have a policy of not registering patients who have a doctor in the area, since these are often problem patients who have a grudge, real or imaginary, with their previous doctor. We may be able to refuse patients under this policy if it has been previously stated.

Or if patients have joined in large numbers, we may be able to declare our list full. Such a large migration of patients, together with a less-than-adequate patient satisfaction survey, would alert the primary care organisation to what is taking place. What is less clear, if the neighbouring practice is insistent it wishes to pursue the corporate work, is what could actually be done about it.

Joanne Harris completed the VTS in 1995 and is a part-time partner at a practice in Ealing, west London ­ she also teaches medical students from Imperial College

Dr Robin Fox'Our senior partner could speak to the neighbour's senior partner'

Multiple patients have voiced their concerns, while the fact they have left a practice, and the written patient records, are confirming that there is indeed a problem.

I would raise this at a partners' meeting. We need to ensure we allocate enough time to this issue and that the meeting is not swamped with other agenda items. If this is not possible, the partners could meet together at another time.

We should bring evidence of our concerns to this meeting. If there is a problem, we have ­ as a partnership and individually ­ to decide what to do next. This will depend in part on the seriousness of the allegations, our relationship with the neighbouring doctors, and our feelings of how likely they are to change the organisation of their practice. Until recently, the practice in question had a good reputation.

It is likely that should the partners rapidly take personal control of the organisation, then once again things could improve. If we as a partnership felt most of the problems were easy-to-rectify organisational ones, our senior partner could speak to its senior partner. This would ensure it was aware of the problem and how seriously we are taking it.

A rapid timeframe would need to be agreed to see improvement in patient care over the next few weeks.Should this not occur, or if our relationship with this partnership was not good enough to raise issues such as this directly, or if the allegations were of a more serious nature ­ misconduct or significant performance concerns, for example ­ then we would liaise with the clinical governance lead of the PCT.

Robin Fox is a GP in Bicester, Oxfordshire

Learning checklist

Effects of outside commitments

Benefits:

  • Can help to prevent burnout in a GP
  • Can allow a GP to develop extra skills in a particular area of practice
  • May enhance earnings
  • Can improve relationships between the practice and other organisations

Disadvantages:·

  • Reduced availability of a partner to patients· Increased workload for colleagues
  • Increased use of locums or sessional GPs with loss of continuity for patients.
  • Difficulties in communication/meetings between partners who work different hours and with staff
  • Distraction of GPs from core activities.

What are the workload implications of new patients?

New patients have been recognised in our global sum calculations to cause 50 per cent more work in their first year in the practice

  • All require summarisation of records and data entry
  • They also require new patient checks and inclusion in chronic disease registers if applicable
  • Many need a series of GP appointments to reassess their medication and diagnoses

Steps to control list size

  • Three possible ways of controlling list size are by changes in the practice area, closing the practice list or by remaining 'open but full'.
  • Changing practice boundaries may reduce travelling time for home visits for you and attached nurses. It is likely to be unpopular with patients who are asked to move. Also, we should be aware that distance from practice is inversely related to consultation rates!
  • List closure is the only way of stopping patients being allocated to the practice. The PCT must approve it and may refuse to fund some enhanced services within the practice.
  • Being 'full but open' allows you to stop accepting new registrations but does not allow you to refuse allocations.

Richard Stokell is a GP in Birkenhead

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