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Something has to give – maybe it’s extended hours

By Richard Hoey

The DH wants GPs to take on commissioning, overseeing out-of-hours and new QOF targets, all for no new cash. Well then, something else will have to go, says Pulse editor By Richard Hoey

GPs are the sponges of the NHS. Drench them in new work and somehow they will suck it all up, and still maintain a semblance of shape.

That at least is the hope of the Department of Health, as it seeks to radically reshape the profession's responsibilities while accelerating the redevelopment of the QOF.

The DH has made clear that the ‘quality premium' for top-notch commissioning will be paid out of existing resources, which means that at best most practices will be earning back money they already get.

Then there's the latest round of QOF revisions. A whole series of work that is apparently now ‘embedded' in clinical practice – from CHD to epilepsy – is set to be scrapped, and replaced with brand new targets on dementia, diabetes and schizophrenia that will be paid for out of the same pot of cash.

The DH must think general practice is not just a sponge, but a magic one at that… but if it was paying attention, it would notice a few telltale signs that the profession is reaching saturation point.

The QOF changes are mundane enough, and you might ask why practices would be too bothered about doing the odd extra test in a patient with dementia, or ensuring everyone with diabetes got their feet checked out.

But if you take each QOF payment to be not a nice juicy inducement, as the popular press would have it, but a package of resources to ensure an element of care is properly funded, then it looks rather different.

In the US, Kaiser Permanente saw sharp declines in performance against quality indicators where even rather tiny incentives where withdrawn. QOF insiders tell me they are genuinely nervous about what will happen when much larger QOF funds are withdrawn.

But this isn't the only area where GPs are starting to suggest that their capacity for workload is not unlimited.

Our out-of-hours survey last week found just one in eight GPs planned to oblige Andrew Lansley by doing on-call shifts themselves when they take over commissioning responsibility.

And then there's a similar survey on extended hours that we publish today, which finds almost two-thirds of GPs will stop offering extended opening should the funding be withdrawn.

That's not a theoretical risk by the way – the Government scrapped the PCT target on extended hours in June, and half of PCTs now say their LESs are under review, while the DH says the future of the DES is also up for discussion.

There's a risk to stopping extended opening of course, given that it would hand Darzi centres a competitive advantage, and possibly raise the hackles of a vocal group of patients and a number of politicians.

But maybe GPs do need to ruffle a few feathers, and symbolically cut the odd service they calculate most patients will not miss, just to demonstrate the point that this is a sponge that is beginning to leak.

Because otherwise, the drenching is likely to continue.

Click here for more from the Editor's Blog By Richard Hoey, Pulse editor