As the third wave of PMS pilots gets on its way, doctors'leaders are complaining that their advice has not been heeded in drafting the new contracts. Ann McGauran reports

Check the small print: that's the advice from the British Medical Association on the core contract for the third wave of personal medical services pilots.

But the caution of doctors' leaders appears to contrast with a rather more enthusiastic response from GPs in the field. Some 2,000 of them have already expressed interest in signing up to the third wave, with many more expected to apply for consideration before the cut-off date at the beginning of next month.

The government has just published an updated edition of its guide to PMS pilots under the 1997 NHS (Primary Care) Act. Interest appears to be high among the 17 new primary care trusts, with every one of North Peterborough PCT's 20 practices wanting to get in on the action.

The NHS plan refers to PMS in the most glowing of terms, seeing it as the key way to set quality standards and deal with specific local health needs, rather than the traditional general medical services Red Book contract.

The government says GMS puts the emphasis on numbers of patients and the quantity of services rather than quality.

That's not the way the BMA sees it.

The contract for pilots starting next April and October specifies that by 2004, patients will get access to a primary care professional within 24 hours. It builds in the NHS plan's commitment to GP access within 48 hours.

The BMA remains unhappy about these targets. Dr John Chisholm, chair of its GPs committee says some patients 'need to be seen in 48 minutes, never mind 48 hours and others would be better served by a longer appointment a few days ahead'.

The organisation has also repeatedly stated that the targets can't be met without a vast boost to GP numbers - more than four times, the 2,000 additional GPs the government pledges to deliver in the plan.

Dr Chisholm's conclusion is that doctors need to 'weigh up quite carefully'whether they can deliver on the contract before they sign up.

If the BMA isn't happy, could it be because of the lack of influence of the medical profession in shaping the contract?

When it was drawing up the contract, the Department of Health drafted in Dr James Kingsland - PMS advisor to the National Association of Primary Care - as an adviser.

But he told HSJ: 'A lot of my clinical advice was not accepted. My advisory work did not feature in the contract. '

He says it ended up being 'largely written by the DoH without formal negotiation with doctors', and that despite 'pressing for specific wording' the 'one liner' about access targets in the contract has 'nothing to do with good clinical practice'.

'What is really needed is better planning, ' he adds.

'If someone has an urgent problem they should be spoken to by someone from the primary care team on that same day. '

He feels the contract's 'arbitrary' wording meant that there is every potential for an awkward GP to say, 'I don't need to see you until 5pm tomorrow'.

Dr Kingsland also questions the contract's insistence on health data for all patients being updated annually.

'If someone comes in with an ingrown toenail and 20 other patients are in that day, is it really appropriate to take that person's blood pressure and ask about smoking and alcohol?'

Other compulsory quality markers are included in the new contract. GPs will have to adhere to the national service frameworks, nurses must receive the full pay review body recommendations, three clinical audits a year have to be undertaken, and 30 hours have to be set aside each year for personal and professional development.

The BMA concedes that a smaller expansion of GP numbers will suffice if the government can attract more nurses and other health professionals.

In November, third-wave applicants for PMS should find out if their applications have been accepted.

But Dr Kingsland says the government should go for 'further clinical debate'before the permanent PMS contract is finalised.

Dr Kingsland insists it is not that he doesn't believe in the reforms. It's those charged with driving them through that he lacks faith in: 'If we allow managers and civil servants to be involved we will end up with something that is unworkable, and the core contract demonstrates that. '

Bureaucracy on the run Chris Town, chief executive of North Peterborough PCT, sees PMS as a way of 'considerably reducing bureaucracy and a way of developing a service based on quality rather than quantity measures'.

He adds: 'The GPs believe it will allow them to free up staff to meet the demands of the NHS plan around clinical audit and revalidation. '

The success of the PCT's walk-in centre may give the BMA some clues about the direction of government thinking on how PMS could radically change access to GPs. North Peterborough deals with 2,600 walk-in patients a month. They are seen by nurses, with only 10 per cent going on to see GPs.