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CAMHS won't see you now

Where to next?

·Make sure GPs are able to use IT systems that suit them

·Sort out inconsistent and incompetent behaviour by PCTs

·Do much more to foster recruitment and retention

Three years ago my mood was one of hopeful optimism that we would get a contract the result of which would lead to the regeneration of our profession. Now I am in a state of shocked disbelief; we have ended up with something that is so flawed and incomplete, something that has been subjected to so much political manipulation, that instead we might see the demise of general practice. So in answering the question 'Where to next?' I am reminded of the lost traveller in Ireland who on asking a local for directions got the reply 'Well if I were you I wouldn't be starting from here'.

Sadly we have to start ­ or rather restart ­ from where we are. First, we need a total revamp of the discredited resource allocation formula, not just a tinkering. The fundamental flaw is that the Carr-Hill formula is largely 'health needs based' whereas GPs have to deliver a service driven by demand. While MPIG has reduced the immediate impact of the formula it is still there; affecting for example the staff pension uplift to the global sum and most practices with expanding lists have seen per-capita income fall since April 1.

We were told practices with low Carr-Hill ratings would be able to make up income through quality payments. But while the factor will no longer be applied to those payments, the use of clinical prevalence will have a similar effect. The Q&O needs to be broadened to include, for example, primary as well as secondary prevention of heart disease. Additionally there needs to be other guaranteed funding streams to ensure other work done by practices in, say, mental or sexual health, is resourced and rewarded.

The contract was meant to ensure the provision of essential practice infrastructure. Those of us who no longer believe in Santa Claus were sceptical about promises of free IT and flexibilities in premises funding. This scepticism has proved to be well-founded. General practice IT is streets ahead of much of the NHS because coalface GPs have been involved in its development. There have been too many disastrous major projects run by managers and IT consultants. We need guarantees we will be able to continue to use systems that suit general practice.

Premises flexibilities are illusory if the basic funding isn't there ­ and it isn't. Many building projects have been stopped. We can't provide a good service in poor, cramped premises ­ and in areas of population growth there may be no surgeries at all. This issue needs to be addressed urgently.

Indeed the whole issue of new practices in growth areas has been missed as there is now no equivalent of the old initial practice allowances. Overstretched practices that wish to concentrate on their existing patients feel inhibited from closing their lists by threats of withdrawal of enhanced services and still have to put up with forced allocations by PCTs. This needs to be resolved.

Indeed the whole issue of inconsistent, incompetent and sometimes ultra vires behaviour by PCTs needs to be addressed. We asked for, and voted for, a national contract. Instead, all over the UK, practices and LMCs are having to spend hours negotiating with PCOs over issues that should have been made clear nationally.

Finally, there needs to be much more to foster recruitment and retention. I have to declare an interest; having reached the age of 60 I would like to see incentives for my generation to continue using our skills and knowledge in practice. Knowing that I can bale out and draw my pension whenever I choose is tempered by the anxiety that by the time I reach 70 I won't have a GP to look after my health.

Eric Rose is a member of Berks and Bucks LMCs

Winners and losers

What sort of practice might be winning from the new contract, and what sort of practice might be losing ­ Dr Stephen Gardiner takes a tongue-in-cheek look at the situation

At their fortnightly sponsored lunchtime GMS2 meeting, the four partners and GP registrar at the Milkit Practice chatted briefly to the young pharmaceutical industry representative about her exciting new product, Metoosartan. They thanked her for coming out to their delightful semi-rural practice, for providing a splendid lunch and for the help that her company had generously provided to ensure all their diabetes patients were screened by a specialist diabetes nurse.

They felt it was very important to be certain that each and every one of their patients who had ever had any microalbuminuria was prescribed her company's product, not only for their patients' benefit but because, almost co-incidentally, it meant that, six months into their new contract, the Milkit Practice was well on the way to capturing the full 1,050 points offered by the Q&O.

The discount she was able to provide for their dispensary might not be passed on to the PCT's drug budget but it had more pressing problems to deal with down the road and the additional practice profits would always come in handy. Roger, one of the partners, thought his wife would be delighted with the new German sports coupé he was buying her to celebrate April's impending windfall. The others heartily agreed.

They too were looking forward to rewarding themselves for their hard work. The £80 hourly rate for their local co-op meant they could readily recoup the money lost from dropping out-of-hours work and they still could close on Saturdays. It seemed likely too that the GPR would join the team soon and her surgical skills and husband who worked for the PCT could only be an asset.

Meanwhile, not that far away in Harshthorpe, Drs Grinn and Bairitt were still struggling to finish their morning surgeries. It had been a long time since they had had the chance to meet up to plan their strategy for dealing with GMS2. It all seemed so unrelated to their daily work. There weren't many points available for helping the unemployed deal with problems caused by poverty and social deprivation.

Things had only become worse since the Government opened a centre for asylum seekers in the town. Not only that, but once they had done the daily 10-15 visits and the evening surgery there was little energy left to do anything but switch the phone over to the increasingly expensive deputising service and collapse into bed together. Occasionally at night they dreamed of the days when, as idealistic newlyweds, they arrived in town, hoping to make a difference to their community. Never did they truly expect to be properly rewarded for their efforts. And so it was.

Most of us, of course, lie somewhere in between the examples above, but perhaps now, at approximately the midway point of the first year of our new contract, it is time to take a minute out of our daily struggle and to raise our heads above the parapet and consider where we are going and how others are doing. We must remember that a divided profession is a beaten profession and that while it is tempting to focus on our own practices we forget the problems of our less fortunate colleagues at our peril.

I hope all of us now have an idea of what we will achieve at the end of March. Our clinical software says we are likely to achieve most of our targets but QMAS seems unable to give us any sensible information. Given that we haven't all been able to assess where to concentrate our efforts due to the lack of appropriate IT help, I trust PCTs have been instructed to err on the side of generosity when agreeing our Q&O points payments. Especially as in the first, and probably the hardest, year we will be receiving hugely less per point than we will in subsequent years for what is likely to be less work once our systems are in place.

Extended and additional services seem to have died a death locally. I still end up taking out sutures for the hospital, doing its blood tests and monitoring DMAs for the rheumatology and gastroenterology departments. I know the LMC says don't do it, but underneath this harsh exterior I still care and can't inconvenience my patients any more because of political wrangling (and yes I know this is the weapon we always beat ourselves with but I've lost some fight in this Indian summer).

Looking through our clinical domains I feel an unusual degree of pride that we have been able to achieve our targets for hypertension control. I never thought we'd be able to do it as I never seem to be able to get anyone's blood pressure down.

Somehow though we have. I only hope our drug budget can survive it and that eventually the patients will learn to tolerate all the side-effects they are having. I mean, not only is it unreasonable to keep filling my appointments with their drug-related problems but they must understand it is better not to be able to stand up due to postural hypotension than it is to be immobile from having a stroke.

The inconsistencies in the contract are interesting too. For example, we have a few patients taking lithium and it works out that we can earn £70 for each blood test we do. Don't tell the phlebotomist. This odd rewarding of effort is also apparent in the holistic payments on offer. The arguments for it are that it ensures practices provide high-quality care across the board, but it is a bit like proportional representation in that small pressure groups can gain disproportionate amounts of power. My practice can earn another £15,750 this year, rising to £31,500 next year, by making sure three elderly spinsters get their flu jabs. No pressure from me of course.

I predict we'll all be feeling slightly fraught at the end of the year when the realisation dawns that a tiny number of unattained targets might have such an unpleasant effect on practice profits, so keep a close eye on your progress.

Stephen Gardiner is a GP in Bridgwater, Somerset

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