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How we can get ready for reform

GPs should start preparing now for clinical audit, quality pay and enhanced services, writes Dr Brian Keighley

believe June 20, 2003 will be seen as the moment of salvation for British general practice. I am now looking forward to the preparations we should be making for next April.

'Working smarter' was always an irritating Department of Health mantra, but it does contain a grain of truth and the contract will certainly change the way we practise. Much of what doctors currently do is routine, mundane and automatic. Only by letting go a little will we cope with an increasing workload.

Nurses are usually excellent at picking up clinical clues, but if they do not, patients will still seek access to doctors no matter what triage we put in their way. Skill-mix is therefore not a negative term and primary care nurses who are already skilled in chronic disease management and triaging urgent problems out of hours will soon learn to recognise when protocols fail to satisfy during daylight hours ­ and to refer on.

'Bean counting' was the constant, pejorative cry of new contract detractors but many of us have actually been doing that for years.

Clinical audit, a professional responsibility, is impossible without good data ­ but it does not require doctors to enter it, and computers can do the processing so long as there is some discipline in coding. Practices must ensure their data is standardised or that software suppliers are writing compatible packages that will transfer existing data. This will allow practices to benefit from extra resources produced by the quality that most are already delivering, and facilitate further improvement.

Once quality payments are assured, underwritten by up-front preparation and aspiration payments, GPs will turn their attention to another significant source of increased income ­ enhanced services. GPs with special interests will be able to develop skills that will introduce added dimensions to general practice that should increase both job satisfaction and our contribution to the totality of NHS care. No longer will we need to go cap in hand to PCOs for study leave. So long as the practice delivers its contracted services, it can make the decisions about how the team will cope with a period of leave.

Perhaps the greatest benefit from the new contract is with out-of-hours and a recognition that a quality daytime service cannot be delivered with a 24/365 obligation. Many urban GPs already opt out, and now this will be available to all but the most remote, its near cost neutrality allowing us to base earnings on a reasonable working week.

This also chimes with the concept of a portfolio career. Younger GPs may wish initially to practise part-time to meet family commitments and spouses' career needs. When mortgage and other financial pressures are at their greatest, however, a lucrative anti-social commitment at night and weekends may be attractive.

This contract gives us all enormous opportunities whether we are young, old, urban, rural, traditional, innovative, PMS or GMS. While doubters believe it is all about money (undoubtedly a major driver) many of us believe that money is the engine for a change for the better while preserving what we do best ­ giving time and consideration to patients who need it.

Above all, this is a time for reconciliation and renewed professional unity. There will be many glitches in contract implementation but this vote gives us a new platform from which to launch a reinvigorated system of general practice for a century that has hardly begun. The framework will at last reward quality rather than quantity, innovation rather than the status quo and a balanced working environment rather than a workaholic ethos. It recognises teamwork without abandoning clinical leadership and introduces a welcome financial lubrication to what we all wish to see ­ proper professionally driven practice that is rooted in shared values and ambitions.

The year 1966 was seen as a milestone, and 1990 as a disaster ­ only time will tell whether 2003 is one or the other. Unity is the way to either capitalise or minimise that final verdict.

Only by letting go a little will we cope with our workload ~

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