GPs have a financial incentive to beat child immunisation targets, but this may compromise their advice to parents - and bring other difficulties. David Tovey argues for a better way

The client goes to the professional. The professional persuades the client of a certain course of action widely acknowledged to have a minimal but genuine risk of morbidity, without acknowledging the fact that their success in persuading the client to accept their advice will help boost their salary, possibly by thousands of pounds.

This course of action receives official government approval. A cause for concern?

Since their introduction under the 1990 GPs' contract, immunisation targets have been taken for granted. Their wisdom is barely questioned. As vaccination rates again become a matter for government concern, we should revisit our strategic approach.

The unacknowledged conflict of interest is at the heart of the problem. Target payments are no trivial matter. A practice like mine, which has five full-time GPs and 9,200 patients, can earn£11,700 a year if the higher targets are met. And some health authorities are incorporating the achievement of upper targets into quality standards on which crucial matters such as staff reimbursement are based.

But trust is a key reason cited by parents who refuse, or consider refusing, immunisations for their children. They simply are not prepared to trust government reassurances about safety, and implicitly those working on behalf of the government are viewed with similar suspicion. Agents of the government whose income partly depends on their persuading enough parents to consent find themselves doubly undermined.

For GPs, too, it is essentially a tawdry business, which implicitly underscores the perception that the only way to ensure they uphold their professional obligations is to bribe them.

Some practices which find themselves just failing to reach a target are reputed to respond by removing unimmunised children from their lists.

Arguably, targets based on outcome and patient consent encourage practices to give disproportionate time to childhood vaccination (and cervical smears) at the expense of other equally important issues. But practices which regularly fail to achieve targets may respond by giving childhood immunisations no priority at all.

That it is often health visitors who give immunisations, and GPs who benefit materially, is also a problem. One can only imagine the outcry from health visitors were it to be suggested that their income should depend on achieving targets.

Most clinicians and managers working in the NHS support the vaccination programme. But at present rates are unsatisfactory, and often worst - as in Lambeth - where poverty is highest.

The New NHS also makes a key objective of agencies working effectively together. But this is utterly out of step with the present reality of GPs, as purchasers, urging health visitors to achieve immunisation targets in order that the doctors benefit materially. The effect is to divide GPs from health visitor colleagues and create resentment.

In today's NHS there is also an increased acknowledgement of the client's role. If this means anything, it allows the possibility that the patient might have different opinions to the professional.

However misguided we believe the patient to be, this is an essential reminder of the dual role of the professional: to give the most authoritative, even-handed advice possible and then to respect the client's right to decide whether to take it.

Solutions can be found which underline principles of agency co-operation, an emphasis on population not practice, and client choice. Rewards to professionals should be based first on evidence of the delivery of advice and informed consent, and second, on a jointly agreed strategic approach between professions on work sharing and reward. Targets could then be raised since no allowance would need to be made for non-consenting parents.

Payment should be based on evidence of a detailed, formal interview with all parents, undertaken by the most appropriate professional. Clinicians would therefore no longer be spurred on by the need to achieve the immunisation and their advice would be more genuine and trustworthy as a result.

To promote a population rather than practice approach, rewards could also be made on a primary care group basis, rather than directly to practices. This would get rid of any incentive simply to remove families from practice lists.

It should not be beyond the capability of clinical leaders and managers to replace a system which is iniquitous and which potentially rewards poor practice with one that reflects the high aspirations embodied in our new NHS. And this might increase immunisation rates as well.