This site is intended for health professionals only

At the heart of general practice since 1960

Buckman...on franchising, IT and polyclinics

In the final part of his interview, Dr Buckman answers more of your questions on the big issues affecting GPs, and reveals that the propaganda surrounding Virgin, Boots and other potential new providers is not what it seems.

In the final part of his interview, Dr Buckman answers more of your questions on the big issues affecting GPs, and reveals that the propaganda surrounding Virgin, Boots and other potential new providers is not what it seems.

Dr John Leigh asks a simple question: how does the GPC plan to respond to the franchising of practices in Birmingham?

Well my initial reaction was it was a wind up and a joke, and I didn't believe it. Now that I've read it, I think it's a joke but I don't think it's a wind up.

I think the franchise model of itself is just another model. I think the Birmingham solution, which is to dragoon GPs into a small number of centres and to persuade the public that private healthcare's alright so they might as well like it, I think that's a most peculiar logic set. You actually want care where patients live, not concentrated in a few buildings. The fact that I'm wearing a uniform of my employer, I suppose it would be, is the absolute antithesis of clinical engagement. I mean, you take the government's ideas of clinical engagement and you turn it right on its head. We're not going to go to clinicians; we're just going to make you work in centres.

We're talking about Heart of Birmingham, we're not really talking about franchising as such, because I work, in a sense, in a franchise. I'm in the NHS franchise. I don't think I've got a thing about the franchising model, I think that's just a way of running the health service. It's not a way I'm particularly enthusiastic about. I know there are GPs who think it's a good idea, it could work, but I think the Birmingham model is just… it would be amusing if it weren't true. I can't imagine that working for a second.

I'm actually very sad to find out that it's actually true, because my initial reaction was somebody's having a bit of a laugh, this was a Monty Python lookalike. And now it turns out it's real, and it's serious, and they really do mean to do this without consultation, without any attempt to see whether doctors or patients think it is a good idea. This has come out of somebody's fevered imagination, and that worries me.

That says precisely what is bad about the health service, that somebody somewhere can have an idea and is in a position of authority where they can make it happen without any attempt at engaging the workers, or the patients. And you've got to engage both of those groups, and indeed the wider public. And the wider public not only have to agree, as in ‘we'll try and persuade them that private healthcare's a good idea'.

Actually what we should be doing is telling them the truth. The truth is this is a device for saving money. This is a device for producing an ‘anybody will do' model … well anybody will not do, people want their doctor, they want their nurse, they want a decent health service. They want familiarity with what will deliver for them and this thing, this franchise doctor, any old doctor, just like a taxi rank, you know, whoever's next on the rank, well, like McDonalds, I think they mention McDonalds specifically in the document. They like the McDonalds model. Well, actually, I don't like the McDonalds model. I prefer the Fortnum and Mason model, if there is a model.

I had eggs and toast there, it was very nice….

In five years time, do you think there will be supermarket surgeries in some parts of the country?

I'm sure it will happen. PCTs are driving themselves mad trying to do it now. I think it will happen in some places.

Let's talk about two separate things. There are quite a few big companies who are very keen to invite GPs in as tenants, and I have not the slightest difficulty with that at all. We have spoken to Boots and Virgin, both of whom deny the way they've been painted by the Government, or I should say by the spokesman for the Government. ‘We're going to have Virgin running healthcare' – that's not what Virgin want. Virgin want to rent their premises out, because they see them as ways of getting in footfall.

They've told you that…?

They've told us that, yes, and their public literature says that. Boots made a public appeal, they're looking for 150 premises. It's not what the Government says ‘they're looking for 150 premises to run 150 practices'. They want 150 premises rented out, and that's because they've identified premises that they think are not economic and they want doctors to come and work in part of their buildings. Why do they want that? It's obvious why they want that, because those doctors are going to write prescriptions that may well end up in the pharmacy as well, and even if they don't, the patients will go into the shop with a pharmacy and may spend money on other things, so that's a landlord-tenant thing. Most of the other supermarkets are very interested in landlord-tenant arrangements, and what's my answer to that? I don't have a problem with that at all.

Just to clarify, when Boots and Virgin spoke to you they told you they didn't have an interest in the other form?

No! Boots particularly went out of their way to tell us how they've had difficulty with dentistry and they've no intention of running General Medical Practice because it wasn't part of their portfolio. But what they did have was excess premises that they wanted to rent out, and our reaction to that, they asked us to help them… that's not right because we don't operate with commercial enterprises, but… they asked us to let GPs know that they had premises available. Fine, that's OK, that's alright.

In terms of the other model then…?

The other model, where they are running healthcare, I'd be very uncomfortable about that. I think you're back to anyone will do, we want fast access, we don't care who it is so long as they've got a qualification and actually the qualification doesn't matter that much just anybody will do. Well, no they won't… patients, if they can get it, value continuity. They value reliability, they value stability, and they don't get that if they don't have a relationship, a longitudinal relationship, with a doctor.

Looking ahead five years again, with that model, do you think it is likely some supermarkets will be running surgeries?

Well I'm sure since some politicians want it to be like that there will some people doing it. I can't see the British public wanting it. But there are people who believe it is a good idea. There are doctors who do not believe in continuity of care. They think it is not important because they see fast, quick, in and out doctor service as something they'd like to do. And if they want to and patients want that kind of service then that's fine, but I think most people on reflection do not want that kind of service, if they can get convenience as well.

One of the GPs asked a question on IT, Dr Paul Thornton, talking about the Secondary Uses Service. His question is: the Department of Health is also claiming that arrangements for the secondary uses database have been endorsed by professional bodies. Would Dr Buckman agree that any such endorsement given by individual BMA representatives on Connecting for Health committees is incompatible with ARM policy?

Yes it is.

Should senior members of the BMA distance themselves more clearly and urgently from the Connecting for Health proposals?

I'd need to know what they were.

The answer is, are there secondary uses for data that is collected through Connecting for Health? No.

Not at all?

No, patients gave that data for specific purposes. It shouldn't be used for anything else.

Where is the GPC at with the Summary Care Record at the moment?

Well, there are two views. One is that the Summary Care Record is a great device for transmitting information between GPs and anybody else in the health service, and for having a unified record. And other people believe it is a breach of trust, that it is actually going to enable all sorts of people who are unauthorised to have access to loads of sources that they shouldn't have. Both of those views are expressed at GPC….. I think that's probably all I want to say.

It's obviously tough for you to steer a path between those two views..

I am steering a path between those two views…. which is why I'm steering at the moment.

For doctors in pilot areas or areas due to become pilots, is there a GPC line of advice you can give?

No because it's a pilot, it's experimental. Although of course as you'd expect the pilot is now being turned into the real thing without any attempt at evaluation.

[Big pause]

I think doctors and the public - because it's all patients and therefore it's the public- have to ask whether the risk of their data being used inappropriately is greater than the potential benefit of intercommunication between different health providers. And I think people just have to ask themselves those questions, and then decide for themselves whether ethically they wish to take one position or another position. You can't half sign up to this. You've either got to agree with it or not agree with it.

What's your personal view?

I don't think I'm meant to express a personal view.

You can't express a personal view?

I don't think I'm meant to, no.

Looking at Choose and Book, there seem to be signs that PCTs in some areas are starting to phase out paper referrals…

They can't do that.

They are trying to do that…

Well they can try. If want to refer a patient with a note wrapped round a brick, I want to see where it says in regulation that I can't do that. It's not natural, but there's nowhere that says I can't… I am obligated to refer patients where appropriate. The GMC says what I can and can't do, not some manager in a PCT somewhere.

The answer is, if I want to refer a patient to a named consultant for example, and I want to write a letter that's outside the Choose and Book arrangement, I'll write one. And if they reject it, I'll make sure that the patient and everybody else understands why it's been rejected. This is an outrageous interference in clinical judgement.

I refer patients to named people, because I think they're good. And I don't refer patients to certain people because I'm not so sure they're good. I don't refer to buildings, I refer to individuals. I don't refer to any old ophthalmologist somewhere in the nearest 100 miles, that's not how I work. And my patients don't expect that. They expect to be referred to someone who I have personal knowledge of if possible, or at least someone whose reputation I can judge who I think it's worth them going to – and not others.

Do you use Choose and Book yourself?

No, I don't. I have tried, but I don't.

And you gave up?

It doesn't work.

Would you consider taking it up again in the future?

No, probably not. But I certainly wouldn't do it under threat from government. What I would do as I've just said is I would explain to patients that their referrals were being refused because I wasn't using a system that I thought was flawed.

At the moment I don't use it because it won't work – I mean, it literally won't work. I couldn't use it if I wanted to. But I have to be convinced that it actually delivers better for patients. What is the point of having an appointments office in a hospital, and then me and my staff spending ages of their time referring patients purely for an aspiration that I understand but that doesn't require Choose and Book to deliver it?

I'm not arguing against patient choice by the way, but actually patient choice wasn't invented by Tony Blair. GPs have been offering patient choice ever since GPs have existed, so we're about six hundred years ahead of Tony Blair. I find if you don't offer patient choice, they don't like it. My patients certainly grumble if I don't offer them a choice – rightly.

Dr Fellerman put in a simple question – you were recently quoted as saying a zero percent pay rise would possibly reduce morale to pre-GMS2 levels. Do you really think the government gives a toss?

No I don't. No. I did say that, that's a correct quote, and I do believe it. Do I believe the government gives a toss? No.

Do you think patients care?

I don't think patients are bothered about GPs' morale. They're bothered about their own GP's morale. They're not bothered about GP morale as an entity.

I think there are those in Government who actually do care. They don't care about GPs necessarily but what they're bothered about is the fact that a sullen, angry workforce can be forced to do anything, but actually it will be a service without energy, it will just be doing what they have to do because they've got no choice.

Yes, you can force people to do anything, eventually you can force them, but that isn't the way you engage senior professionals who you're paying a lot of money to. You pay them money because they make clinical decisions, that's the reason why I'm paid. If I'm just a robot delivering what somebody promises based on what they're advisers have told them to say, that's not the way to run the health service.

So do I think patients care? I think they care about my personal morale… The Government as a body, no I don't think they're remotely interested. Ministers? I think some of them actually are bothered, yes, I think some of the ministers are bothered. Whether all the people who surround them are bothered I'm not so sure.

But in answer to the general question do people give a toss, no, I don't think so.

The Darzi Next Stage Review and separately the polyclinic proposals in London. You're a London GP and you've said previously you're not a big fan of polyclinics…

No I'm not.

You've also said you think to some extent PCTs will bung a label on something and call it a polyclinic. How much of this do you think will be real change, and how much will be cosmetic?

Well if PCTs don't induce cosmetic changes they'll be fired, so if I was a PCT chief exec, I'd be sending out sticky labels to put on every building I could possibly get my hands on and calling it a polyclinic, it doesn't matter what it was before.

And some real change as well?

There will be some real things as well I guess, and there will be some patients who actually don't care about their GP and anybody will do. But as I've said already three times, anybody will not do.

It's the extreme antithesis of personal care. Either you offer personal care to people where the relationship between a doctor and a patient is crucial to the delivery of healthcare, and to the professional's enjoyment, may I say, or you say this doesn't matter, basically we're running a casualty type service, where anybody who walks in will see a doctor who's reasonably competent. Well, I think that's a witless service. It's a service without wit, humanity, drive, enthusiasm, industry. It's just treading water. It's the kind of thing somebody would think about if they didn't know much about general practice.

One of the things they seem to be particularly targeting is smaller practices, and you yourself work in a smaller practice.

I'm a single hander.

Would you ever move into a polyclinic?

No. I work in a corporate group, a circle of doctors who work together and share premises, staff and expenses, but not profits or patients. But we do cover for each other as well. That's a corporate group – the corporate group model is not new, it's over 50 years old, but it hasn't taken off hugely.

Corporate groups actually are almost polyclinics, there's not a huge difference between them, but the big difference is, we work together for our own industry rather than benefiting some private concern with remote shareholders. I don't see myself as vertically integrated with secondary care. I'm there as a primary care physician for people who think I'm good enough to be their doctor.

There seem to be declining numbers of smaller practices and single-handers… is that an ongoing trend?

Well, it's been government policy for 20 years, that small practices are somehow inferior. But ask patients. Patients like it. Look at the QOF scores, look at the accessibility, look at patient satisfaction. Look at indeed almost any measure. There are some things obviously that I can't do because I'm not big enough, but I think patients like small practices. There are a lot of people who like personal care.

What do you think of the various different aspects of the Tories' plans that they've come out with recently?

I don't think much of the idea of renegotiating the contract, I'm not going through that again, and I'm not sure what good it will do.

Their idea for, well they call it commissioning with real budgets but they really mean fundholding by another name, well I don't agree to it with any enthusiasm but we could work with it.

Do you think a Tory government would be easier for GPs to work with?

No, this is mythology. This is a fanciful notion that you elect a government and something changes. Our ship of state isn't run by politicians. People delude themselves by personalising it, you see, Mr X, the Minister or the Secretary of State or whatever, as if these are the people that run the health service, and they don't. So does it make a difference if you have an election? It's the same horse, different flies. It's a different enterprise.

They don't change. They'll dance to a different tune, but it'll look pretty similar to the old tune. I think at the moment the difference between the three political parties is actually quite small. Whereas in the other home countries, the political parties' differences are quite substantial, and we'll have to see where that leads as well.

Finally, in terms of exception reporting, are there are any plans to reduce the number of reasons for which GPs can exception report?

No, there are no plans, no it's not being discussed, no I wouldn't consider it. But I don't think it's going to happen, so I may as well forget it. It's never ever been mentioned, never. Well, it has been mentioned in previous years, but in the last year, it has never come into anybody's conversation. There is no prospect of it and it is not being negotiated and we are not considering it.

...on the effects of the spin campaign ...on the effects of the spin campaign

I don't think patients are bothered about GPs' morale. They're bothered about their own GP's morale. They're not bothered about GP morale as an entity.

...on what difference the Tories would make ...on what difference the Tories would make

It's the same horse, different flies. They'll dance to a different tune, but it'll sound pretty similar to the old tune.


Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say