Dr Phil Hammond, broadcaster and GP returner in Bristol

How has the new contract affected your consultation behaviour? I suspect it depends on your attitude to both the nGMS contract and your computer system.

One particularly irritating program uses screen ‘pop-ups’ to highlight contractual demands (and the number of points on offer by fulfilling them). The pop-up has to be sorted before the patient records can be accessed, so the consultation might start with: “I’m so sorry to hear of the death of your cat. Has the grieving process led you, or anyone else in your house, to take up smoking?”

The same program won’t let you issue a prescription without first entering a definitive diagnosis or naming the problem.

If I’m honest, a lot of my consultations never reach the dizzy heights of a definitive diagnosis. How can you possibly pigeonhole “I’ve got a little itch on the end of my nose and my toes go whoosh, whoosh”? And sometimes the patient has so many problems I can’t just prioritise one at random.

I also have a bad habit of prescribing first and diagnosing later, especially when I’m under pressure. Alas, target driven consultations generally prefer a more linear approach to keep the software happy.

How much of an inconvenience you find these developments depends on whether you feel a prescriptive, risk-assessment approach to primary care is a move in the right direction or the death of humane medicine. GPs I’ve spoken to seem pretty much divided on this.

Some are fully behind the emphasis on traditionally neglected areas like stroke and chronic disease management, and are quite happy to get their heads down and hit as many targets as possible before the money runs out. Others couldn’t give a toss about their quality points.

As a pragmatist, I think it’s probably best to play the game, take the money and then invest it in something that will really improve the quality of life of doctors and patients (like an inhouse cinema).

Really keen practices are cold calling patients to check on smoking status or sending out mass mail shots. Others are letting the patients use self-booking software in the waiting room, which frees up the receptionists for clinical tasks such as BMI checks and urinalysis.

Nurse practitioners have taken over treating any disease that can be covered by an algorithm (although they are still allowed to think), and by the time the counsellor’s work is done, GPs are left with all the complex, indefinable or insoluble problems. As one GP put it: “When will there be a template for suffering?”

And let’s not forget the satisfaction surveys. Do you shrug them off and consult as normal, or do you find yourself bending over backwards for even the most irritating patients to gain a few points more? And do you curse patients who are satisfied but who can’t be bothered to fill in the survey?

Perhaps the biggest challenge to the consultation comes with the patient choice agenda. By the end of 2005, at the point of referral, patients should be offered a choice of four or five providers for all elective care. It’ll be largely GPs who are left to navigate the maze of comparative risk and informed choice, all in less than 10 minutes.

It’s a tough task, but I suspect it’ll still come down to “How long will I have to wait?” and “Where can I park?”

Guidelines in Practice, January 2005, Volume 8(1)
© 2004 MGP Ltd
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