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Gold, incentives and meh

How I hope contract will solve patient allocations

Dr Anthony Pickering on why and how the contract must tackle the allocations crisis

llocation of patients to practices has long been a problem, but whereas previously anxieties were focused on difficult behaviour, now the problem is compounded by increasing numbers against a background of workload and recruitment difficulties.

In my area, Northampton, notwithstanding a helpful PCT, there is a real problem of recruitment. Indeed, at the latest count there were six unfilled whole-time equivalent GP vacancies. One practice has lost three of its five GPs.

The local GP recruitment problem is the equivalent of 12,000 allocations, on top of which there were 4,000 formal allocations last year, a 10-fold increase over two years.

To make matters worse, Northampton is a rapidly growing town. We believe 10 per cent of the population (20,000 people) are not registered with a GP. This is a financial disaster for the PCT and a timebomb for GPs.

There are also health, cultural and language problems. These magnify the time commitment for each allocated patient. A disproportionate number of allocated patients have addiction or mental health problems. Refugees may, in addition, have more general health problems.

Cultural differences may result in failure to take up preventive health measures, many of which feature in target payments to the practice. Not surprisingly, many of the local practices have closed their lists but even so, the average list size per whole-time equivalent GP is well above 2,000.

The LMC has engaged with the PCT to introduce measures to limit damage. The PCT has established a PMS town centre practice specifically for the homeless, for refugees and for those with a drug problem. The PCT and the LMC are trying to ensure patients are allocated in a balanced way, according to the number of GPs and the geographical area. We have secure facilities for consultations with violent patients.

As evidenced by the worsening recruitment problems, however, this is insufficient.

As a member of the LMC I hope the new contract will emphasise that patients without GPs are a PCT problem, to be solved by the PCT and not dumped on to GPs under a gentleman's agreement dating back to the last century. We and our staff must be protected from aggression, and GP income should not suffer as a result of patient choice in not taking up preventive measures.

Similarly, the behaviour of patients in respect of accepting the constraints of chronic disease surveillance must be allowed for when assessing practice performance.

The PCT must continue to recruit GPs, but it will have to make a particularly attractive offer, both in financial and professional terms. The new contract would have to allow considerable local flexibility in this area. Plans exist to make Northampton a 'teaching PCT' as part of which there would be the possibility of combining general practice with other work.

It is vital the contract allows all NHS work to be pensionable. In respect of existing practices, the financial penalties consequent upon a failure to reach targets might be avoided if the target population were more sensitively defined. A substantially increased capitation fee for allocated patients might be introduced.

The LMC would also wish to see, under the new contract, security for monies allocated to GP development so they were not used to balance the books after prescribing overspends consequent upon following NICE guidance and NSFs.

We hope the PCT might be given the flexibility to operate sensibly.

A substantially increased capitation fee for allocations might be introduced ~

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