Indicators revealed last week as part of the 2012/13 contract will handicap practices in urban areas, GPs warned.

GPs will be expected to continue to deliver prescribing targets dropped from the QOF to make way for the A&E indicators. Negotiators also raised the threshold at which practices earn maximum points for dozens of other QOF indicators.

From April 2012, GPs must review and plan to reduce avoidable A&E admissions under indicators added to the QOF quality and productivity (QP) domain.

Wiltshire GP Dr Gavin Jamie, a QOF statistics expert, called the A&E indicators a 'shocker'. 'Prescribing was about the only really sensible bit of QP. GPs will now have a paper chase discussing A&E attendance. There is very little GPs can do about attendance in A&E.'

Dr Prakash Chandra, chairman of Newham LMC in east London, said the move would disadvantage practices with large migrant populations. 'Patients in this part of London include immigrants coming from eastern Europe.

'The only thing they know is hospital. They have no knowledge of primary or secondary care.'

Encouraging such patients to visit a GP instead of A&E is therefore 'very difficult', he said. Dr Chandra warned that educating patients on how to use the NHS required PCT input and resources. 'Without that, practices will struggle.'

Dr Jamie suggested GPs could struggle to meet raised QOF thresholds. 'This will hit practices and may well result in an increase in exception reporting,' he said.

Workload pressures may increase further after the BMA told GPs to continue working on prescribing targets no longer supported by pay from April. A joint statement by the BMA and NHS Employers added that outlying practices would be expected to continue to participate in external peer review during 2012/13.

Dr Chandra said: 'Practices are so inundated with so many different types of work, it will be difficult for them to cope with that.'

QOF changes
Changes to quality and productivity indicators will require GPs to review and plan to reduce A&E admissions. QOF thresholds across many clinical domains will be increased. Practices will still be expected to deliver targets for which funding has been dropped.