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Diary of a practice manager: when QOF fault lies in our registrars

6 June 2008

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Edward Picot
Practice Manager

Edward Picot has been a practice manager for 17 years. His website,, features a collection of his writing, poetry, short stories and animations

For the first time in several years, we don’t have a registrar, writes Edward Picot, which means that we’ve gone from having 18 sessions of GP appointments per week to just 10.

Naturally, we were a bit worried about how we would cope. Registrars are meant to be supernumerary, but there’s no denying that if they’re any good you can soon get used to having them around.

The doctors anticipated horrendously long surgeries. The reception staff were apprehensive that there wouldn’t be enough appointments, and they’d find themselves constantly wrangling with patients about whether their symptoms were really urgent or not.

As it turns out, however, things haven’t been too bad. The three remaining GPs – Jack, the principal, and the two retainers who work two sessions a week each – are all seeing more patients per session, which is only to be expected. But although we’ve been through a busy time, with a fluey cold rampaging around the town, we haven’t been all that stretched.

Home visits are the trickiest thing. In a rural practice, with patients spread out all over the countryside, the difference between two GPs with two visits each and one with four can be enormous – depending on where the patients concerned live. And if the GPs have busy surgeries followed by lots of visits, the next thing to suffer is paperwork: reading the post and processing results.

On the other hand, there are some unexpected bonuses. Things have suddenly gone quiet on the nursing front. The number of blood tests and electrocardiograms being requested has gone down in quite a startling fashion. Ditto for X-ray and ultrasound requests. Referrals made under the two-week rule have fallen too: in fact, we seem to be making fewer referrals right across
the board.

It certainly wouldn’t be fair to say that all registrars are trigger happy when it comes to referrals and investigations, while experienced GPs are invariably conservative and resource-conscious. But it does stand to reason that doctors who feel unsure of themselves are more likely to “play it safe”. As a result, practices without registrars may well do better under practice-based commissioning.

They may also do better with their Quality and Outcomes Framework (QOF) points. I recently discovered that we were losing 10 points for Depression 2 (“Depression Assessment Tool Used”). On investigation, it turned out that these were all down to the registrar, who had incautiously diagnosed a whole string of patients as depressed, without recording any proper assessments.

Registrars can’t really be blamed for making mistakes like this: the QOF system is a complicated one, and people are bound to slip up a few times before they get the hang of it – but the problem is that just as you get them trained they leave, and you’ve got to start all over again with a new one.

Of course, people have to have registrars, otherwise we’ll never get any new GPs. All the same, with procedural restraints getting tighter all the time, you do wonder if the current levels of reimbursement are really adequate.