New Contract For General Practitioners Research Articles

73 THE NEW CHRONIC DISEASE MANAGEMENT PROGRAMME FOR GENERAL PRACTITIONERS: MAKING THE CASE FOR ITS REVISION TO INCLUDE DEMENTIA

Abstract Background A significant component of the new contract for general practitioners is the chronic disease management programme (CDMP for GPs). Although dementia can be framed as a chronic disease, it was not included in this programme. Its exclusion raises a number of questions including: Should dementia be framed as a chronic disease? Is it feasible to include dementia in a future revised CDMP for GPs? What are the likely benefits and potential risks? Methods This presentation focuses on two elements of a larger mixed-methods study, namely: (i) in-depth analysis of the CDMP for GPs, involving a review of the programme’s three main components to test the feasibility of extending it to incorporate dementia; and (ii) qualitative content analysis of data from semi-structured interviews with 12 stakeholders whose expertise is in dementia, chronic disease or both. Both elements were informed by a literature review. Results No consensus was found about whether dementia should be framed as a chronic disease. Results showed that it is feasible to extend the annual preventative programme of the CDMP for GPs to include additional modifiable dementia risk factors. While opportunistic case finding for identifying undiagnosed dementia cannot be recommended, a tool is available that would enable GPs identify people with dementia for enrolment on the structured treatment programme. Expected benefits from including dementia in the CDMP for GPs include integrated care pathways, better GP access and record-keeping and greater emphasis on primary and secondary prevention. Expected risks include excessive costs, caregiver burden, increased GP workload and sub-optimal care due to lack of specialist dementia training. Conclusion There is a compelling case to support dementia risk reduction in the CDMP for GPs. However, the programme’s current emphasis on self-management and rigidly planned visits could prove problematic for people with dementia and would need substantial revision.

Implications of the new GP contract

A new contract for general practitioners (GPs) was introduced in the UK on 1 April 2004 which has implications for secondary care. In particular, the contract means that GPs can opt out of out-of-hours care, and accident & emergency services have voiced their concern that their workload may increase as a result. The new contract provides the potential for a rise in GPs' salaries by two means: through the provision of the Quality and Outcomes Framework which includes the management of 10 common chronic diseases; and through 'Enhanced Services', which are a series of optional 'extra' more specialised services with national specified standards that can be commissioned by primary care organisations (PCOs).

Double standards

Negotiations on the new consultant contract are clearly at a delicate stage. With the announcement in the summer of the launch of negotiations on a new contract for general practitioners, the Government could find itself fighting a war on two fronts. Analysts of twentieth-century military history will avow that this is not a desirable position to be in.

Stress and the new contract for general practitioners

The impact of a major organizational change on general practitioners in the UK was assessed using a postal questionnaire during July‐August 1990. The results were compared with those obtained in a previous survey in November 1987. A total of 917 (61 per cent response rate) general practitioners completed the questionnaire measuring aspects of the job causing stress, job satisfaction and mental wellbeing. Compared with 1987, doctors in 1990 experienced significantly decreased levels of job satisfaction and reported levels of somatic anxiety and depression were higher. The stress associated with the demands of the job and patients′ expectations, practice administration and routine medical work, role stress and the use of social support as a coping strategy were the strongest predictors of job dissatisfaction and poor psychological wellbeing.

Professional Power and Managerial Control: The Case of GP Assessments of the Over‐75S

ABSTRACTThe creation of Family Health Services Authorities from the old Family Practitioner Committees in 1990 marked a turning point in the introduction of managerialism into primary health care services. One of the FHSAs' first responsibilities was the administration of a new Contract for General Practitioners, which had generated considerable opposition from within the profession. This Contract included a new requirement for GPs to make, each year, a written offer of a health check, at home, to all patients aged 75 and over.Particular scepticism was expressed by GPs about the value and effectiveness of routine annual assessments's of this kind. Drawing on interviews with FHSA managers and their professional medical and nursing advisors, this paper examines the strategies adopted by FHSAs in tackling the administration of this particularly controversial requirement. Although apparently effective in the short‐term, the paper concludes that these strategies may have considerable longer‐term short‐comings. The constraints and pressures experienced by FHSAs and the strategies employed to deal with them provide a useful insight into the tensions generated in the course of developing a managerial relationship with professional practitioners who have traditionally enjoyed very high levels of autonomy and independence.

General practitioners, skin lesions and the new contract

We reviewed all skin lesions received in our laboratory from general practitioners (GPs) during a three-month period before the introduction of the new contract for GPs and during the same period a year later. For comparison we also reviewed skin lesions received from the general and plastic surgeons. Particular attention was paid to the completeness of excision. There was a significant increase in the number of skin lesions removed in general practice after the introduction of the new contract. Both benign and malignant lesions were more likely to be incompletely excised by GPs compared with surgeons. The GPs first noted to carry out minor surgery after the new contract came into force were less likely to have completely excised lesions than their more experienced colleagues. We suggest the future monitoring of lesions removed in general practice, possibly by the formation of a joint audit group.

Cervical screening in Perth and Kinross since introduction of the new contract.

To determine changes in the cervical screening service since the introduction of the new general practitioner contract on 1 April 1990. Analysis of computerised records of cervical screening both before and after introduction of the new contract. General practices in Perth and Kinross Unit, Tayside. A total of 30,071 women aged 21-60 on 26 general practitioner partnership lists. Percentage average of target population for cervical screening in each practice for first three quarters on introduction of the contract. Perth and Kinross Unit completed a computerised cervical screening call programme in July 1989, which produced an increase from 71% to 78% in the mean percentage of women aged 20-60 who had had cervical smear tests within 5.5 years. Six months after the introduction of the new general practitioner contract the mean population coverage was increased to 85% in women aged 21-60 and only four practices had not attained the 80% upper target compared with 10 on 1 April 1990. Detailed examination of randomly selected practices immediately before the new contract was introduced showed an average artificial list inflation of 4.3% in health board records when compared with practice records, a hysterectomy rate of 6.2%, and an additional 3% of women who were considered to be ineligible for smear testing due to putative virginity or illness or infirmity, or both. There was a considerable shift away from use of well woman clinics (2.7% of smears in 1990 compared with 5.6% in 1988) for taking cervical smears, potentially threatening the long term viability of the clinics. The introduction of the new contract for general practitioners has brought about a further sustained increase in population coverage for cervical screening in a small Scottish unit with a stable population, well motivated general practitioners, and a fully integrated computerised call and recall system based on the community health index. To optimise the screening service revision of the targets levels is necessary.