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Was I right when I refused to give police sicknote?

Three GPs share their approach to a practice dilemma

Nurses can't cope with the quality and outcome target

Case history

Your practice is aiming for 1,000 quality and outcome points. The practice manager has emphasised that many points depend on carrying out opportunistic checks on patients when they come in.

The doctors are fitting these in during routine 10-minute consultations without significantly overrunning but the two practice nurses, who have 10-minute appointments for routine blood pressure checks, venepuncture and so on, say they can't manage and need separate appointments.

This will put severe pressure on nurse appointments or mean increasing their hours.

You were hoping to devolve more chronic disease management to the nurses.

Dr Richard Stokell

'The practice could consider offering the nurses financial incentives'

I would approach this problem in a positive frame of mind. I understand that nurses have different professional skills and work patterns to doctors. Collecting data opportunistically for the new contract does increase their workload and it is unrealistic to expect it all to be done with current resources.

Initially the partners need to meet with the practice manager. I would hope to explore the pressures GPs are feeling as a result of having to collect additional data. I would also hope to overcome some of the implied resentment towards the nurses' attitude.

It may be possible to improve their activity by providing additional administrative support from ancillary staff. I would also be thinking in terms of the nurses' training needs, perhaps for IT skills or time management.

We will probably have to increase our nursing provision. Taking on a health care assistant to improve skills mix could be cost-effective. We could consider offering the nurses financial incentives, perhaps linked to the quality and outcomes framework.

One of the partners needs to meet with the nurses and the practice manager and listen with empathy to their difficulties.

The nurses need to understand the advantages of taking an opportunistic approach to collecting data. I would show them how much of the practice population we can cover if everyone works together.

The nurses could develop an action plan to meet the increased demands on them if the partners agree to meet the costs of possible changes. I would hope to follow up their individual training needs through the staff appraisal system.

The most important thing is that we retain our staff. Losing key personnel at this stage is likely to prevent us making progress in the quality and outcomes framework.

Richard Stokell completed the VTS in 1988 and currently practises in Birkenhead, Merseyside ­ he is also a GP trainer and course organiser

Dr Catherine Laraman

'The contract is here to stay ­ that means doing the job or not being paid'

The new contract has brought changes for everyone in primary care, and this can make people feel threatened. This is particularly true for nurses, who weren't even in on the vote. They may not be fully aware of the nuts and bolts of the contract and may feel it marks a change in direction away from their traditional 'caring' role.

Whichever way we voted, the contract is here to stay. That means doing the job or not being paid. Period. The first step has to be to get everyone on board. People feel less threatened when they have a sense of control over their situation. Now is an excellent opportunity to look at everyone's working practices. Perhaps there needs to be some 'myth busting'.

Opportunistic checks such as giving lifestyle advice and taking blood pressures should be part of good clinical practice anyway. We only need to get in the habit of documenting this in order to play the game of 'points mean prizes'.

The contract actually releases us from various constraints, including how we pick and choose our skill mix. There is scope for discussion with the nurses about how they would like to 'spend' their nursing hours. What about employing a health care assistant to carry out some of the tasks that don't require a G grade? Do the nurses feel their IT skills could do with being updated? Could life be made easier with tick boxes or macros?

I would encourage the nurses to take the helm in a particular interest area, for example being lead nurse in asthma and COPD. I'd ask them to think about linking monitoring areas together, for example a clinic for looking at a patient's diabetes and cardiovascular care. This is to ensure nothing is missed and to encourage time efficiency.

Regularly practising these new habits should ensure it becomes second nature this time next year. Enough of the whining. Let's get on with the job!

Catherine Laraman is a partner in a practice in Penmaenmawr, north Wales ­ she completed the VTS in 1999

Dr Melanie Wynne-Jones

'Unless the practice performs well its long-term viability may be threatened'

We need to review skill mix, working relationships and practice organisation. But we will need to be careful. We don't want to lose valued and experienced nurses, and we must ensure they feel we have taken their concerns into account.

Historical issues and outside influences such as the PCO and the local practice nurse group may also be informing the nurses' reaction. Or it may be the traditional belief that nurses 'have more time to listen'.

As doctors, we too find it difficult to get everything done in 10 minutes and we aim to delegate wherever possible. Have we applied the same logic to the nurses? What are we expecting them to achieve during their surgery sessions? Do they have appropriate administrative support, or are we paying highly-trained nurses to restock doctors' rooms, complete simple paperwork or carry out other unnecessary tasks?

Monitoring and improving performance is the practice manager's responsibility, although he or she will need clinical guidance from the GPs. The big question of course is why we haven't considered employing a health care assistant who could relieve the nurses of routine tasks at a lower hourly rate.

Trained health care assistants are in demand, but we should ask the practice manager to prepare a business case for employing one or, if necessary, training someone ourselves. The manager will need to involve the nurses, because they may feel threatened by devolving some of their responsibilities, or (like us) feel that removing the 'easy stuff' will make their consultations more intensive and demanding. The nurses may also have training needs we need to address in order for them to perform better.

Taking the skill-mix argument further, let's not forget patients. We need to manage their expectations (for example, whether they should consult a doctor or a nurse about minor illness) and we must inform and involve them if we change the way we provide services. They can also help by completing lifestyle questionnaires in the waiting room!

Every member of the practice team, including the nurses, needs to understand that unless the practice performs well under the new contract, its long-term viability may be threatened.

Introducing an element of performance-related pay, probably in the form of a bonus tied to the number of quality and outcome points we achieve, may encourage everyone to rise to the challenge.

Melanie Wynne-Jones has been

a GP for 20 years ­ she is a trainer and appraiser in

Marple, Cheshire

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