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Has contract really changed practice?

I read your article (April 5) and reflected at length with my own experience as a GP who has worked alongside nurses in the provision of PMS services since the first wave of pilots in 1998. At that time there was only one nurse-led PMS practice in the country.

I think we have to ask why nurses who wish to develop primary care services have to adopt such approaches to the medical profession. General practice is by and large an independent contractor-run provider service, delivering franchised care to patients under the terms and conditions of various contractual models.

With PMS, and now new GMS, there is liberalisation of this service delivery, such that the provision of essential services to patients is no longer exclusive to independent medical contractors (either singlehanded or in a partnership). There is certainly plenty of work to go round.

Until April 1, a patient had to be registered with a GP and with that registration came the 24x7 responsibility for patient care. That was applied in law even with out-of-hours co-operatives and group partnerships. It was an invidious position for many salaried GPs like myself as such terms could not be easily applied to an employment contract.

But with GMS2 – and consequently new PMS – that issue of responsibility no longer applies in the same way. It is a PCO that is now responsible for guaranteeing a local population access to health care services.

That responsibility is devolved by PCOs to primary care providers – and out-of-hours providers – through substantive and legally-binding contracts.

These contracts require a balanced workforce to ensure a team-based approach to delivering services to patients. Hence it stipulates the requirement for at least one GP among the list of performers within any one provider unit.

It is the performers – and they have to be listed in the contract document – who are responsible for clinical care. The provider unit, whether it is led by doctors or nurses (or a PCO), has to ensure an adequate mix of performers to deliver essential services as a minimum or be in breach of contract.

Under these circumstances I do not believe it is necessarily relevant or appropriate to suggest the provider type is the main determinant of patient care. It is the performer mix and the environment in which they practise that is the key.

As most GPs would appreciate, that is not too dissimilar to

doctor-led general practice as we know it today.

Dr CK Khong



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