PCT managers constantly send us spreadsheets to show how well or poorly we are performing, and how much NHS money we could save.
But the one thing these calculations never include is our time. Yet as we all know, time is money. GPs' time is precious - not that you would think it from the way that many PCT managers ignore it.
Take medication swaps. Clearly the NHS would save on its drugs bill if patients on expensive medication could be switched to cheaper alternatives. But these simplistic calculations don't include the real cost of the exercise. It takes time to identify the patients on the more costly preparations, and to check that the swap is clinically appropriate for a given individual. Then we have to explain the swap, implement the exchange, monitor the response, perhaps increment the dose and perform confirmatory blood tests. It takes time.
Although PCT managers may not acknowledge these time burdens, these are certainly understood by practices: indeed, one of my colleagues refuses to swap patients to lisinopril because it takes too many consultations to titrate the dose.
Then there are referral protocols. Our PCT won't allow consultants to cross-refer: instead, each case has to be passed back to the GP. This convoluted procedure will fritter away vast amounts of GPs' time.
As GP recently reported (GP, 21 October), insensitive hospital behaviour can also increase practice workload - for example, when GPs are obliged to write prescriptions for drugs which should have been dispensed from the outpatient pharmacy. Additionally, many PCT commissioners now insist that any patient who misses a hospital appointment cannot be seen again without a new GP referral.
Initiatives, such as the introduction of detailed care pathways, are all very well, but they need assessing more widely and introducing more carefully.
Crucially, these wider costings should also include laboratory tests and relevant imaging: control of expenditure from every source will become increasingly important in new cash-strapped clinical commissioning groups.