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At the heart of general practice since 1960

Shipman's hospital years to be probed

Pulse returns to five typical GPs to see how they are dealing with the demands of the new contract

Rural GP

Dr Gordon Baird

Sandhead, Wigtownshire

Practice profile

Rural, GMS

·2 partners

·1 nurse

·3 administration staff

1,600 patients

High proportion of elderly CHD and diabetes (4% of patients)

Quality points aspiration

747

How have the last three months been?

I am trying to ignore the contract still. I don't want consultations to be driven by an agenda that is neither my patients' nor my own. I have spent time removing Post-it notes from patients' notes reminding me to check them for smoking and blood pressure.

We are about to take on a new member of staff and we would really like to build a new surgery.

The surgery is next to my house, and the contract requires us to be open for longer, so I would like to move.

Are you referring more patients for any particular conditions?

Yes, for heart failure. They are all supposed to get echocardiography. Before, if there was no clinical doubt, I would not have referred them for an echo. If you were certain someone did have a heart condition there was no need to have a test to spot the blinking obvious but now we do. We are also referring more for diabetes to reach the targets.

What is your policy on exception reporting?

I'm not clear on when you can do that. I don't know what the policy is. Someone else deals with that.

What has been the reaction from patients?

I think a lot of patients are now more concerned about their cholesterol and worrying about nonsense. There are more worried well.

If you lower the cholesterol in one person who is sick, you can make one in 20 or 30 people better. People are extrapolating that into the well population.

It's more and more work for less and less return. There is a law of diminishing return.

What changes have you made to your partnership agreement?

None but I will look into it. By the time you get round to looking at that the partnership is in real trouble anyway, but I will look at it.

Urban GP

Dr Clare Davison

Newham, east London

Practice profile

Urban, PMS

·6 partners, 2 salaried GPs

·2.5 nurse practitioners

·5 administration staff

·10 part-time receptionists

10,500 patients

Very mixed practice population, including a range of minority ethnic groups and people on low income

Quality points aspiration

1,012

How has the contract changed relationships in your practice?

One of the senior partners commented today that we don't talk to each other any more. We used to do repeat prescriptions over a cup of coffee but now it is all on computer. It is a shame.

What changes have you made to your partnership agreement?

We had to have a new partnership agreement because we had a couple of new partners. The only thing that has changed is that there used to be an option in the old contract for a sabbatical and there isn't in the new one, so we put that in the practice agreement.

What preparations have you made for your Q&O visit?

Our visit is in November but we will have the system audited before the team come in. As clinicians we have had to call patients in more often but a lot of the work is going on upstairs with the administration staff.

What is your policy on exception reporting?

Exception reporting feels very loose, it doesn't feel like at all clear guidance. Even within the practice we have very different ideas on what should be exception reported.

What has been the reaction from patients?

I do think some patients are noticing they are being seen more frequently. We are doing a patient questionnaire soon and it will be interesting to see the results of that.

Commuter-belt GP

Dr Shah-naz Whitear

Hadleigh, Essex

Practice profile

Suburban, GMS

·4 whole-time equivalents

·1 salaried GP

·1.5 nurse practitioners

·2 health care assistants

11,500 patients

Relatively affluent area with high numbers of elderly and commuters

Quality points aspiration

900

How have the last three months been?

The most noticeable thing is when patients leave, I now check if I've entered the data for the contract. But getting all the data in on time with the dates required is a problem. Sometimes we will have a patient who has come in only a few weeks earlier, and who had a normal blood pressure, only for the computer to say they need to come in again.

Are you referring more patients for any particular conditions?

I have been referring more diabetic checks and health care assistant check-ups. I haven't been referring to hospitals more, because we are getting more patients sorted out in the practice.

What is your policy on exception reporting?

I'm not really clear on it. Sometimes, when you need to exception a patient on

?-blockers because they are taking another drug, you have to log them down as allergic, which is silly.

How has the contract changed relationships in your practice?

It's probably for the better. When I started we didn't work as a team. We are communicating more with every member of staff, and working more as a team.

Is your workload slackening off yet?

No, it's terrible. The paperwork has stacked up.

Dispensing GP

Dr David Bevan

Upwell, Cambridgeshire

Practice profile

Rural, dispensing, PMS

·5 whole-time equivalent GPs

·1 nurse practitioner in training

8,300 patients

Quality points aspiration

1,001

How have the last three months been?

They have been quite busy. There is no doubt that consultation length has risen as a result of the prescription-led bits of the contract.

We have been identifying and auditing some of the issues thrown up by the Q&O. There is stuff in the framework in every practice that represents data management that wasn't as high a profile previously. Note summarising has been interesting as we had some building work done which left us with a three-month backlog.

What preparations have you made for your Q&O visit?

We have had the date for our visit for the past two months and the initial data trawl went to the PCT last week on a CD ROM. The PCT has behaved straightforwardly and honourably.

How is the out-of-hours situation progressing in your area?

We went live with out-of-hours on Thursday night and I did the first shift. The decision to go live was only made a fortnight ago after appeals were made to local GPs to staff the rotas while the PCT try to recruit salaried doctors.

What has been the reaction from patients?

They haven't noticed, except that the doctor is even more likely to be tapping into the computer rather than talking to them.

Is your workload slackening off yet?

We won't see our workload slackening off. I very much see that we want to increase both our own time and other practice staff time to get ahead of the game.

Singlehanded GP

Dr Michael Smyth

Maguiresbridge, Co. Fermanagh

Practice profile

Singlehanded, GMS

·1 practice nurse

·1.5 receptionists

·1 full-time practice manager/ primary care pharmacist

2,000 patients

List dominated by teenagers

and over-30s; rheumatic diseases most prevalent

Quality points aspiration

850

How has the contract changed relationships in the practice?

If anything my practice manager is under more strain than me. She's been working very hard and I haven't been brought into things too much.

What preparations are you making for your Q&O visit?

We are improving our clinical indicators and a lot of patients are being asked whether they smoke. We may have to start referring more patients with regard to echoes.

How is the out-of-hours situation progressing?

The health board want to take responsibility from October 1 but with the option they could still force us to maintain things up to January 1. We are prepared to do that ­ but only for three months. Shift rates could have been better.

What is your policy on exception reporting?

We are trying to maximise everything without exception reporting and ensuring we have the right codes for proper exception reporting as a last option.

What has been the reaction from patients?

I don't believe they see a lot of change but they may have noticed we are a bit more stressed than usual trying to maintain points. That can sometimes be a bit incongruous in consultations.

We've got alerts on our computer system but rather than doing the whole gambit in 10 minutes we are doing it in small bits ­ that's why we are asking about smoking in the next week or two. There's more prescribing going on and more patients are on statins and ACE inhibitors.

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