You are concerned about the impact of the QOF and certain DESs on your ability to focus on your patients’ agenda. Your partners remind you your income depends on them. You propose that your practice drops some QOF indicators and the dementia screening DES, but your partners seem unwilling. Should you challenge them on this – and what should you do if you are still unable to reach agreement after serious debate?
Dr Thomas Block: ‘Look at the whole QOF and DES spectrum to see which areas are worthwhile’
Conflicts of this nature are common these days. As a practice, you have a limited capacity in terms of personnel, space and time. We (older?) doctors are hard-wired to do everything in our power to promote the wellbeing of patients. On the other hand, we have a contract that bribes us to do things that are not necessarily beneficial.
More and more, we need to be selective about what we take on and sometimes we have to make the decision not to do a QOF activity or a DES because the income generated does not justify the work involved.
My view would be that if you are not convinced dementia screening is intrinsically worthwhile or sufficiently remunerative, instead of looking at this one area, you should look at the whole QOF and DES spectrum and cherry-pick those areas that are worth doing, whether for clinical or financial reasons.
Doing so would restrict some of your activity, but at the same time maximise the income you can get in return for an acceptable workload.
You should also be looking to maximise the work that can be delegated to nurses and healthcare assistants.
Finally, you should consider exploring other revenue streams, which may be better than the QOF in terms of remuneration for the effort involved.
Dr Thomas Bloch is a GP in Broadway, Worcestershire.
Dr Peter Ilves: ‘Work with neighbouring practices to integrate services’
Hand on heart, you may be able to see that delivering a particular QOF indicator or enhanced service would take more effort than would be justified by the rewards produced. But if your practice does not sign up, you may start to introduce inequality of delivery to your patient population.
It may be time to work with the practices around you. Start to have discussions with colleagues in local practices but also with your locality commissioning team.
It is time to think in networks, to integrate delivery of some services. It is time to realise that ensuring equality for a local population goes beyond the borders of a single practice population. This is about localities and similar populations with similar needs.
Once you have systems to do this for one service, you can apply the same modelling to others. You can now see how one practice in a locality delivers one set of services while another offers others. Maybe it is time to share back-office and management functions across a locality, for example.
If you set up networks you can ensure equality of delivery for a whole population. The borders and the differences between surgeries do not matter and you all increase your QOF scores and create income you may want to pool for other initiatives.
Dr Peter Ilves is a GP in Roehampton and the GP clinical lead for West Wandsworth CCG.
Justin Cumberlege: ‘Refer to your partnership deed when you discuss the issue’
Fighting your partners is best avoided, but an up-to-date partnership deed should give you guidance. It should state how you agree to drop, or take on, services. Persuasion is better than argument, but the best outcome is an agreed solution.
Remember that more income does not necessarily mean increased drawings. Will the income from the service be more than the cost of providing it? Even if it is, if you can show that you can spend your time doing something else that will produce the same or more income with fewer resources, your partners should be persuaded that you do that.
Practices that have worked out the costs of providing certain services have wisely dropped one or two in order to maximise income in other areas and be better off in the end. However, the smart money is on working with neighbouring practices so that between you, as a network sharing patients, you are able to provide all the services and share the income through cross-referrals.
So if your practice population justifies one or two GPs providing particular services, the sensible approach where you have a network of several practices is for just a few GPs in the network to specialise in that service for all the network’s patient population, and to have in place a contract and protocol for cross-referring patients.
Through federations, we have seen practices working effectively together to share services in just such a way.
Justin Cumberlege is a partner at solicitors Carter Lemon Camerons LLP and leads their healthcare team.
