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Published: 12/09/2002, Volume II2, No. 5822 Page 14

Thirty per cent of GPs in England will be working under personal medical services contracts by next month.

But will throwing away the 'red book'ease the recruitment crisis?

Mark Gould reports With the government taking a battering on several fronts, you might have thought it would trumpet good news, particularly about achieving what it said it would do.

It is therefore perhaps surprising that the Department of Health has not made more of the news that it will reach its target of 30 per cent of GPs in England working under personal medical services contracts - allowing more flexible ways of working - by October.

This might be six months late, but let's be charitable - a target is a target. In April, the government's target date, HSJ reported that less than 20 per cent were signed up to this new way of working. From October, the DoH now says, some 1,700 pilots will be in operation, covering around 20 per cent of patients in England.

So what is behind this renewed leap of faith in moving away from the standard general medical services contract, the so-called 'red book', towards the more flexible forms of working and salaried status available under PMS?

The answer is money, says Dr Laurence Buckman, a member of the British Medical Association's GP committee. 'I have been telling GPs to take the money from PMS, get the cheque spent and then, after April 2003, look at the new GP contract, which will be a lot better, and sign up for it. Wait another 12 months and see how many are still in [PMS]. The new GP contract will give them more money, more rewards and far less paperwork than PMS or the old contract.'

A national survey of first-wave PMS pilots carried out by the Royal College of GPs published in June shows that in cash termsthere is some truth in what Dr Buckman says, particularly for those who opted for PMS at an early stage. These PMS-practice GPs received an average annual increase in income of£33,000, compared to£10,600 for GPs on GMS contracts.

However, it also found that GPs opting for salaried status under PMS took a pay cut: down from an average£52,000 to£43,000. This was offset by employment benefits, including paid sickness leave, educational leave, maternity leave, an NHS pension and an income unaffected by target payments.

'Salaried GPs benefited from reduced hours and freedom from out-of-hours and administrative responsibilities, ' the report states.

Dr Buckman believes that the government's drive for PMS is a weapon to divide and conquer the powerful BMA GP lobby while telling the public it is hitting targets. He also says care to marginalised groups has been forgotten.

The RCGP disagrees. 'PMS can generate service change and benefit patients as a result of increased flexibility, ' its survey concludes. It found that first-wave pilots had a 'high degree of success in achieving their objectives'.

'Overall, PMS pilots provide evidence of better and more equitable practice.' However, the report warns that progress in areas of high need and improving access for vulnerable populations may not automatically extend to later pilots.

NHS Alliance PMS spokesperson Dr Ron Singer says success in reaching out to the marginalised was patchy. 'In some cases, yes, it has done the job, especially in trust-led pilots.'

But, he says, such was the DoH's eagerness to sign up GPs to PMS that resources were not allocated in terms of absolute need. 'If you have a list size of 1,300 patients per GP, even if you were in an affluent area with a low workload, you could sign up because they wanted to fulfil targets.'

The DoH says PMS has been 'helpful in attracting GPs to areas where historically recruitment and retention has been problematic'.

But the RCGP survey found that PMS had 'little impact on recruitment problems in deprived areas' and retention was described as 'average'. In general it found that recruitment to salaried posts in deprived urban areas was quicker, but there were fewer applicants per vacancy than the national average.

It says: 'Many of the applicants were previously inactive or parttime GPs, suggesting that salaried posts may increase staff numbers by encouraging inactive GPs back to the NHS.'

NHS Confederation chief executive Gill Morgan feels that a whole new version of PMS may be needed: 'After the dust has settled on the new GMS contract, people have got to sit down and think about how we make sure that the next wave of PMS allows opportunity for innovation.' l On a role: 'I am still doing the same paperwork' The Department of Health says personal medical services provides an opportunity for enhanced roles for nurses.However, the Royal College of GPs report (see above) concludes that restrictions and ambiguities over referrals and prescribing have hampered the development nurses' role.

One inner city personal medical services pilot nurse, who wants to remain anonymous, feels immense frustration about the bureaucracy and the lack of clarity on better skill-mix - supposed benefits of PMS: 'PMS was meant to throw away the red book, but there has been an increase in administration in terms of producing contract reports and setting the contract itself.The primary care trust still requires the same smear and immunisation target information, so I am still doing the same paperwork as before.

'The government created money to employ nurse practitioners in PMS, but not practice nurses or healthcare assistants, so it seems that nurse practitioners have been recruited into posts that they are not needed for.

'My current post should be a practice nurse not a nurse practitioner, so I am wasted.'