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Showdown at high noon

In the fourth instalment of the PBC diaries, our protagonist finds consultants duelling with GPSIs for non-generalist work

In the fourth instalment of the PBC diaries, our protagonist finds consultants duelling with GPSIs for non-generalist work


Dr Peter Weaving is a GP in north Cumbria whose bumpy course through the waters of practice-based commissioning started with a year as chair of a 38-practice consortium before the group became a victim of PCT reorganisation. He then became a ‘company man'as a PCT locality lead, and now finds himself caught in the middle of interprofessional warfare...

I quit! I've had it up to here! I can't stand another meeting with GPs,consultants and various managers thrashing out the bleedin'obvious when I should clearly be at home having my tea and watching Heroes.

Secondary care here is drowning under a flood of referrals from primary care.

Elsewhere in the country any acute trust worth its salt would open its arms wide and welcome the cash flow – not so with us. To achieve foundation trust status, our local acute trust needs to downsize, achieve financial balance and hit all its waiting list targets. So you'd think our efforts to set up community anticoagulation, dermatology services and orthopaedic screening services would be appreciated. If only.

In the old days GPs and consultants were united against their common foe – the managers. Now, a new area of conflict has arisen between doctors in secondary care and the not-so-generalist GPSIs.

The GPSI role initially seemed a rare winwin for acute and primary care. Trained and mentored by a friendly local consultant in their specialist subject, the GP exports their new skills to primary care. The patient gets a friendly, safe and competent service closerto home; the GPSI gets job satisfaction. The acute trust has routine tasks removed from its waiting list, freeing up consultant capacity for more specialist work and making it easier to hit the 18-week target. And the consultant calls the GPSI to discuss Volvo dealerships and golf courses.

But then it all changed – as if Choose and Book wasn't bad enough for consultants, PBC and Payment by Results came along to measure every item of activity, procedure, admission and consultation (kerr-CHING!).

The consultant realised the GPSI was creaming off the routine work, being paid for it and charging his GP mates' PBC budget less than the going rate at the local trust.

Cherry-picking, just like those blighters from the independent sector.

Suddenly it's not in the consultant's interests to help these competitors into the marketplace, so they are too busy to train them,supervise them or provide that all important mentorship that is a requirement for a GPSI's continued professional standing.

This is not an academic discussion. Efficient and high-quality providers will attract business, poor ones will go out of business. Departments that do not make a profit for their acute trust, or at least break even, will close.

This system,which will prune down trusts in an overhospitalised large urban conurbation, can have adverse effects in rural areas by forcing patients to travel further to hospitals.

My problem now is how to introduce competition that raises the bar in both primary and secondary care without leaving holes into which the poor patient will tumble.

Answers on a postcard please...

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