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CAMHS won't see you now

When to say yes – and how to say no – to your PCO’s demands

Dr Tony Grewal offers advice on how to avoid a deluge of paperwork and workload

Dr Tony Grewal offers advice on how to avoid a deluge of paperwork and workload

Very few of us are lucky enough to have had the brave new world of scrutiny and performance management by primary care organisations pass us by unnoticed. No week passes without requirements, requests and demands, many of which are time-consuming, onerous, of dubious value and apparently driven by an alien agenda that take us away from our function – of seeing and managing patients who are ill, think they are ill or wish to avoid becoming ill. At the same time we have to manage a small or medium-sized business and balance the cost of care against the need to balance the books. Looking after our patients, our staff, our families and ourselves is a heavy burden; to provide

PCOs and the Government with the information and action they require to make the system work frequently seems unnecessary, burdensome and irrelevant.

Although PCOs can, and do, have good relationships with their practices, some can, and sometimes do, turn nasty very quickly. They have huge discretion in many areas of general practice funding and support, and have been given an increasing range of investigative and punitive powers. Clinical governance, contract regulations and the performers' list regulations give PCOs the capacity to punish practices, and sadly, some do. (Did you know that ‘suitability' and ‘efficiency', as decided by a PCO-constituted internal panel, are grounds for removing you from a performers' list?)

So how should we deal with the deluge? How, in the face of this macho management style, do we decide what we must do, what we can treat cosmetically and what we can, and should, discard?

Is the request compulsory?

Your first question must be: does this requirement have a basis in statute, regulation or contract? If this is the claim, ask the PCO to ‘clarify and identify the statutory, regulatory or contractual basis for this' – the golden question, but be prepared for an obfuscatory response – they often won't know. If it does turn out to have a contractual basis, you have little option but to comply (or be able to provide evidence of compliance – not quite the same thing). If in doubt, ask your LMC – it is our job to know, or at least to know where to find out.

If not compulsory, is it beneficial?

Your second question should be: if I cannot be compelled to do this, does it suit our practice to do so? A simple but effective set of criteria to aid such decision-making is:

Will this action increase or improve:

• my practice's funding?

• my wellbeing?

• my patients' health?

• my patients' wellbeing?

These may be placed in any order, depending on your personal priorities for your practice. Those of you who value your practice teams may wish to substitute ‘my' for ‘our'; the truly high-minded may add the public good to the list.

Is the suggested activity cost-effective?

Do not forget to look at the cost-benefit ratio. If any practice activity places too high a burden on your resources (human, temporal and financial), then other more beneficial activities may have to be reduced. This is a difficult exercise, will never be totally accurate (unless you pay management consultants to do it – and even then...) and will, quite rightly, produce different results from practice to practice.

Many of us tend to do something because it is there, without the assessment that is second nature to successful businesspeople. Even more commonly, once an activity has become embedded, we continue with it uncritically and without review.

Never fail to set criteria and a timescale for judging the success or otherwise of any initiative, and have the courage to admit that your initial enthusiasm was misplaced.

Is it politically desirable?

Finally, although you must be prepared to act assertively, I recommend you spare a thought for how well you wish your PCO to think of you. PCOs are themselves subject to enormous managerial, departmental and Government pressure. They can only fulfil these requirements through their ‘performers'. Should they be subject to criticism or worse as a result of your reluctance to promulgate their schemes, then you may find yourself in their sharp-focus view, and this is an increasingly uncomfortable place to be.

Don't be bullied, have the courage of your convictions (and ask your LMC for help or support) but also remember that sometimes negotiation around an initiative that is important to a PCO or the Government may allow you to achieve a positive result (which is, after all, what our noble and valiant GPC negotiators do all the time).

Below is a simple flow-chart illustrating the decision-making process, and a table giving some personal examples from my own practice.

Dr Tony Grewal is a GP in West Drayton, Middlesex, and vice-chair of Hillingdon LMC

PCO requests The decision-making process

PCO has offered LES for secondary care activity validation exercise, after LMC consultation, with appropriate software and training provided

Criteria for consideration
• Improved hospital communications will improve patient safety (patients' health)
• Fewer wasted appointment for patients, less time wasted chasing data, fewer delays in instituted recommended management, fewer spurious DNA letters, possible savings for reinvestment (patients' wellbeing)
• LES payments (practice funding)
• Better care for patients, more efficient use of time, less frustration and irritation (patients' health)

Review at three months by practice manager
• No improvements in communications and so on
(patients' health, patients' wellbeing, my happiness)
• Hugely time-intensive process (staff time costs more than LES payments) – cost-benefit analysis
Review with LMC/PCO
• Software and data extraction cannot be improved
• Current commissioning process does not allow significant pressure to be applied to secondary care provider, no evidence of intention to improve, contractual timescales prevent savings in year
• Other GPs report similar concerns, PCO offers no solutions
Practice review
• No benefit to patients in foreseeable future
(patients' health, patients' wellbeing)
• No reduction in difficulties/time wasted
(patients' wellbeing, my wellbeing)
• Cost-benefit analysis reveals return on staff time does not cover costs (practice funding)

• Withdraw from LES
• Describe difficulties or reason for withdrawal to the PCO
• Explore other mechanisms for improvement through LMC, commissioning and so on
• Consider reassessment if new LES is produced, with fresh
cost-benefit analysis and mechanism and timescale for improvements being crucial criteria

Know when to say yes - and how to say no - to your PCO's demands How my practice has decided whether to agree to PCO requests

Click here for Dr Grewal's table of when to agree to PCO requests.

Guest editor

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