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At the heart of general practice since 1960

Why GPs must try to understand PCOs

Dr Peter Saul is both a GP and

a member of his local health board and

so sees the contract from both sides of the fence

Most GPs in practice have seen the implementation of the new contract as a bit of a headache with impossible deadlines and reams of paperwork to get sorted. But spare a thought for those of us who sit on the boards of PCOs and their counterparts elsewhere in the UK.

The headache has turned into a migraine as we look at the contract from both directions! Talk to GP colleagues about implementation and they will rage on about PCOs, accusing them of at best incompetence and at worst conspiracy. Well as a GP member of a local health board ­ Welsh for PCO ­ it has been interesting to see it from both sides of the fence.

Let us get a few things straight. To start with the contract has been at least as confusing and challenging for PCOs as for practices. Remember that many of these organisations are relatively new and under-resourced. Also they often lack guidance and support from above. My board hasn't got everything right, but where there have been problems it has. invariably been cock-up rather than conspiracy.

There is absolutely no question of trying to get 'one up' on GP colleagues, of 'hidden agendas', or of trying to 'settle old scores'.

One of the issues that really taxed our chief executive was the legal status of the practices as private or NHS bodies. Most had opted for the former and our chief executive let his imagination run riot thinking he would be dragged from court to court by practices over the slightest dispute. Eventually he calmed down and adopted the same pragmatic approach of most practices in the area ­ don't worry about things too much, just get on with the job and wait to see how things work out.

Negotiations over quality points have also been an issue. The way payments are structured means there are advantages to cash-flow if practices overestimate their aspiration points.

The problem for the PCO is that it will have to allocate this cash and if at the end of the year the money is unused, it will be lost to GMS because it will be too late to redirect it. So if you have had an argument over these figures it is not because your PCO is mean.

Money also influences the development of enhanced services. My board is terrified of these because if too many are agreed, and activity increases from last year, then there won't be enough money to go around.

It's going to be at least a year before major changes are started in this area because the effects on the budget won't be known till then.

Out-of-hours is seen as being perhaps the biggest risk area for PCOs. Some have already contracted with providers but many, including mine, are still going through the process of getting things organised, and of course the financial numbers are still guesswork. GPs are in a peculiar position. Most have opted out but they continue to lobby PCOs about service provision because they want a good-quality service for patients and they don't want to have to 'pick up the pieces' the next morning.

And of course the GPs want the service set up yesterday. So there is pressure from all directions on managers: to get a cost-effective service, to have regard for quality and to fend off anxieties from the general public and local politicians. But unlike much of the contract, there are real choices here and therefore plenty of decisions to be made, some of them difficult ones perhaps.

PCOs are dependent on regions for their information and sometimes this is late in coming and confused. The only thing definite is the need to meet a deadline.

This shouldn't be an excuse but it has resulted in PCOs keeping practices in the dark while they get things sorted, and this has not helped develop an atmosphere of trust. We've had newsletters, but I wonder if there's been enough personal contact.

Remember that, just as at GP practices, all this work has taken place on top of the

routine stuff that is needed every day by people under every bit as much pressure as practice staff.

So be tolerant and be nice to your PCO!

Peter Saul is a GP in Rhos near Wrexham and a local health board member

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