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Prepare now to enhance your contract income

Since PCTs are having trouble finding funds for enhanced services, and since people other than GPs can provide them, Dr Eric Rose says a careful case needs to be prepared to obtain the work

Under the new contract there will be three main income streams. Most practices have discovered to their dismay that global sums, even when boosted by MPIG, will not provide an adequate income.

Quality payments will provide additional money but most practices will also be relying on providing and being paid for at least some of the enhanced services.

There are, however, two potential problems. First, PCTs are saying they haven't got enough money for all enhanced services. Second, even if they do find funds, there is no actual right for practices to be the preferred provider. In theory at least

the PCT could decide that it could provide childhood immunisations, for example, more cheaply by using health visitors.

This creates a paradox because while most of us will want to get a share of enhanced services, we must ensure we don't end up underselling ourselves in our anxiety to get the work. Bids and business plans must be prepared carefully.

Even if you think you know the difference between essential, additional and enhanced services it is vital to read and reread both volumes of the blue books.

I am surprised to find some GPs, and a considerable number of practice managers too, have not seen the second, thicker volume that is the supporting documentation. In one practice where everyone looked blank when I mentioned its existence I conducted a search and found it on a shelf in the senior partner's room still in its postal wrapper.

This second volume is vital because it contains precise definitions and specifications for the directed and national enhanced services.

Local enhanced services are not detailed as they will by definition be commissioned to cover a specific local need.

After studying the blue books you will have a clear idea which of your present activities are covered by the definition of enhanced services and will be able to consider whether your practice wishes to continue with that service.

If you do then you must be sure you understand and can meet the specifications. These are not arduous but with minor surgery, for example, you will have to demonstrate to the PCT that you have adequate facilities, a trained nurse to assist, instruments that are properly sterilised and speciments which are sent for histology. Among requirements for anticoagulant monitoring are a register of patients, a call and recall system and education and management plans for each patient.

All this involves a sea change in attitudes on the part of GPs, PCTs and hospital colleagues. In the past we have often had work such as anticoagulant monitoring and shared care of patients on second-line treatments for arthritis foisted upon us without any thought about whether we have the necessary resources or skills.

In addition many GPs have done this work without any payment. Now there will be payment, but only if we able to convince the PCT that we do have the resources and skills.

The opposite side of the coin is that unless the PCT commissions the service there will be no obligation to provide it so GPs must learn to say 'no' and must mean it.

There is little doubt that some managers will resort to the usual blackmail of 'patients will suffer if you don't do it' or 'yours is the only practice that won't co-operate'. There may also be attempts to pay less than the price ranges laid down in the second blue book.

These tactics will be easier to resist if practices work together through their LMC. LMCs will also have a vital role in helping practices to argue the case for local enhanced services where there is a specific need.

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