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At the heart of general practice since 1960

Dr Laurence Buckman: in his own words

On the eve of the 2009 LMCs conference, Dr Laurence Buckman talks to By Steve Nowottny about the patient survey, swine flu, scorecards and why he doesn't do personal attacks and is never optimistic.

By Steve Nowottny

On the eve of the 2009 LMCs conference, Dr Laurence Buckman talks to By Steve Nowottny about the patient survey, swine flu, scorecards and why he doesn't do personal attacks and is never optimistic.

What are the key issues you expect to dominate this year's LMCs conference?

I think the key issue is consolidating what we have, and raising the quality profile of general practice. I think GPs are tired of being criticised, and actually want to celebrate what they do. We're looking at how practices can display their quality better, be more responsive to patients, look at things like patient participation groups which is obviously part of that, and really look at enhancing their position. Because if we don't look at improving the image of general practice – and that's not to say improving general practice – but if we don't improve the image we are going to have all sorts of problems in the competitive world that we've now been forced to inhabit.

Practices are wrestling with the difficulty of having to compete with commercialised practices, often on a very uneven playing field, and they will be concerned about that. It also plays to the revalidation agenda, how does revalidation fit into this, practice accreditation, how does that fit into this, that's one large area. And the consolidation area involves looking at how gross practice resources – by which I mean both global sum and correction factor – will develop over the years, and how QOF will develop, in the new environment in which NICE are intimately involved.

So that's probably the main things.

In terms of how things have gone over the past year, there have been a lot of changes, with QOF and so on. What's your mood going into the conference, are you optimistic?

No, I'm never optimistic…

It's been a better year than last year, it couldn't have been much worse. It's been difficult, but we have come out with a pay rise, albeit a very tiny one. I don't think you could utter three resounding cheers for that, but…

But in the current climate…?

Yes, in the current climate it's OK.

The QOF prevalence changes have met with very mixed fortunes. You find the majority of GPs wanted it – the reversion to no change, to unadulterated QOF scores – thought it was a good thing, it was desirable. And yet there are very substantial numbers of GPs, particularly in London but not only there, who have taken quite a hammering on it.

Looking through the motions, there's one that said that despite the consequences having been unintended, the motion was calling for the changes to be undone. With the benefit of hindsight, do you have any regrets?

No, not at all. Not at all. Despite the fact that I personally lost money on it. No, I don't regret it at all. The prevalence changes were inherently, by virtue of being deliberately discriminatory, they were unfair, and the fact that they were unfair in my favour doesn't make them any better.

They were unfair. And as a London doctor, I step back from my personal position and I say … the reward ought to go to those people who see more people with diseases. It shouldn't be ameliorated. And if I was a GP in the Midlands or in other places where quite clearly they did not receive sufficient funding, I'd say well this is quite right. And that's what the debate is about.

There'll be people who say "how could you have done this, even worse, how could you have done this to yourself, but how could you have done it, you've done things to London doctors". Of course it's not just London doctors, the people who have suffered most are university practices all over the UK. The biggest practice to suffer is in Scotland, but a university practice nevertheless..

"How could you do this?" Well, what was going on before was not fair. So, no, if I had to do it again, I'd do it again. I am personally sorry because it's affected me personally, but it was still the right thing to do. The right thing to do is to be fair.

And if most GPs across the country say what was going on before was unfair, and conference year after year has said it was unfair, having initially changed its mind as to whether they wanted us to do it… It's all very well standing up to conference, but standing up to conference on something that is unfair is very mistaken. If you can't argue either on a political or a fairness ticket, there's not a lot you can argue on.

Moving on to what's in the news this week, the patient survey is obviously a big issue.

I am aware that it is, yes…

A simple question: are practices likely to get back the money they've lost?

I don't know.

Do you think they have a shot at it?

Well I think there are two things… you don't realise you're asking two questions.

Question one. If you appeal, are you likely to get your money back? I think that has to be tested through court, through the judicial process. I couldn't speculate on that.

Do I believe there will be any practices that could have a case that I – as a non-lawyer – think is a runner, yes absolutely. But you're speaking to the wrong man, seeing as I'm not a judge or a lawyer.

But I think there are practices where the results are absolutely counter-intuitive. And I will be impressed to see the justification for those.

On a wider case, which is: is the process unfair? Indeed was it intended to be like this? In other words, is this an accident? I think we've still got some talking to the Government to do. We are talking to the Government very actively.

It may not have been an accident?

No, I think it was an accident.

It was an accident?

Yes, I think it was an accident. I think they didn't realise… well, that's not quite true. We spent a lot of time telling them what we thought would happen. Now, we don't have facts across the whole of the UK, but the facts in Scotland plus anecdote everywhere else appear to match. So I suspect when facts emerge, they'll emerge along the lines of the Scottish facts.

Now it could be said, well of course you're only going to hear from people who've lost. You're only going to hear from people who've done well. But my point to you last week was you can't do well, all you can do is not have money taken away.

I personally have had a very small amount of money taken away, but there are people who have had tens of thousands of pounds taken away. And quite often, people have had money taken away having achieved the same results as last year. Now that can't be right. That cannot be right, that you lose money for getting the same result as last year.

When did you first become aware that this might be an unintended consequence of the way the survey was developed?

The thing I've just mentioned, we never thought could happen. That thing I've just mentioned…But the conduct of the postal survey, and the threshold arrangements, it became obvious that could happen. I think our real concern was if the numbers of respondents was very low, relative to the practice size, and we kept on saying what will happen in that circumstance? And we were told well, the statistics show that won't happen.

Well, I'm afraid that's exactly what's happened. Practices that have got their stats have got some results which are counter-intuitive.

So you were aware it could be an issue, and were told it wouldn't be?

No, we were aware it could be an issue, we pointed out what could happen. We were told the solution was the stats. Well, I'm afraid it hasn't worked. So now we've got to work with Government to try and find a solution – Governments, because it's a four-country problem, I suspect.

It's slightly speculative, because we haven't got four country figures. But the anecdotes that I'm sure you've been getting look like the other three countries are going to get the same results as Scotland. Although you're only going to hear from people who aren't happy…

They seek us out…

I'm sure… But I would suspect that Scotland is mirrored in the other three countries.

That is very worrying – for a central plank of Government policy to be defunded, when the rest of the NHS puts more money in when things don't go right, here we take money away when things don't go right. That seems remarkably perverse. So I will carry on talking to Government.

I think every time I've interviewed you, I've asked you about your relations with Government. This year's LMCs conference sees motions of no confidence in Gordon Brown and Ben Bradshaw – which way will you be advising people to vote?

I will tell people that we don't do personal. I don't believe in attacking individuals, they are carrying out Government policy. Now, you could argue that Gordon Brown is the Government… I would ask a question of anyone posing the motion, what do they think will be the consequence of saying this? How is this going to improve relations with the Prime Minister.

I think he probably couldn't care less either way, but it certainly isn't going to make it easier to talk to the Prime Minister. So I would have thought while it's a nice kneejerk reflection of anger, after the pleasure of two minutes, then what?

So I will tell people I think we should move to next business… It's never a good idea to have a vote of confidence in somebody, so I just wouldn't vote on it. I think it's unfortunate.

You mentioned a couple of weeks ago at the LMCs conference in Crawley – don't be too certain things will be better under the Tories. They seem to have some fairly wide-reaching plans, removing fixed practice boundaries and so on…

They do. Well, that particular thing we don't have a great deal of difficulty with, but there are some things they like that we don't like. But we will work with any Government in power, whoever they are. I think taking a stand against individuals is a mistake, however nasty they be. We don't have to play that game. If they've done that, OK, but we don't have to do that.

Do you think your job representing GPs would be harder if the Conservatives get in?

No. No. The Conservatives will be exactly the same. The people who run the health service won't be any different, so I don't think it'll change much.

Swine flu. When it first became an issue a few weeks ago, there were quite a lot of local problems for GPs, with facemasks and so on. Is that now all resolved do you think?

No, but it sure put the breeze up everybody and made them tidy things up quicker. I think a false start or a stuttering start has actually done the health service a favour, because people have been given a warning, wake up, you've got a few months to get yourself straight.

Do you think there will be a pandemic? Professor John Oxford was quoted that he thinks it's still ‘silently spreading'?

Yes, I think that's quite plausible.

And there have been various projections in terms of how many extra cases GP practices would face in a pandemic – in reality how do you think GPs will cope?

Can't tell. You're speaking to the wrong man, I'm just a GP, I'm not a virologist.

I think it's going to spread and I think it's spreading silently, and I think it doesn't appear to be as bad as people were expecting, but it may turn out to be less attenuated in the autumn. So I think we're in for a tough old autumn.

Having had that stuttering start, are GP practices now ready?

I think they're much more prepared. I think those that weren't bothered at all have really had a wake up call, saying get on with it, buddy up, get yourself organised, plan your practice, plan your business continuity.

Less of an issue this year, but still obviously a big issue, Darzi centres. We did a story yesterday on a GP-led health centre in Plymouth which is advertising in a cinema to draw in patients. It's obviously not breaking any rules, but do you think that ordinary GPs will have to market themselves in a similar way?

I think most GPs will regard that as a real sadness, as a really sad thing. If that's what it's come to.

I suppose if you're out-advertised in a local area, you'll have to advertise as well in order to survive. I think a lot of people will see that as a real waste of resource – as if we haven't got enough trouble with money, we now have to spend money on advertising as well. Oh dear…

What do you make of GPs in Kent running a service in Somerset, or where GPs are running practices across the country?

I think that's… I think that's very sad that that's happened. I wish the GP consortia that are doing it the best of luck, but they are spreading themselves very thin. They'd be much more sensible to run their own practices in their own area, not operating remote practices which are not hugely different from commercial outfits except they are run by NHS GPs, who are at least trying hard to keep the NHS going.

It was inevitable that that would happen. So I hope it works, I hope that they employ people properly and I hope the practices thrive. But if all they're doing is setting up to damage neighbouring practices, which a lot of them are being forced to do, that's not a good idea.

The King's Fund recently launched an inquiry into general practice [GPC and BMA Council member Dr] Kailash Chand wrote a column describing it as an attack on general practice. Do you agree?

Well… there are always two views. The word inquiry is an unfortunate word, because inquiry does sound like, it's very close to the word inquisition. Which is never a term of endearment.

There are two reasons why you might be interested to know about quality. One of which is because you're interest to know about quality – I'm proud of the quality GPs offer, so let them look… But the word inquiry carries a slightly unfortunately tone. The fact that th BMA are excluded from that inquiry, other than as just another stakeholder, I think that's unfortunate. I think… I think it will be used by those who like to do such things as another weapon to bash GPs with.

Which is unfortunate because I think the people involved with it are quite sincere, decent people. I don't think they intend for it to be damaging to GPs.

So you weren't invited to be part of it?

No, I wasn't. I wasn't.

I have been approached since, will we give evidence. Well yes of course we will, we'll try and help them as much as we can, but we're not involved at the centre of it. And you would have thought that the only GP representative organisation might actually be invited to represent GPs. You might have thought that.

Another big issue we're looking at at the moment is balanced scorecards – they seem to actually now be becoming reality and being published. Firstly, what do you make of them, and secondly, is there anything LMCs can do to stop these or are they inevitable?

The Government can choose whatever it likes to tell the PCTs to do. So it's not in our gift to control it.

Most GPs don't like balanced scorecards, because they think they misrepresent what the practices provide. Our jobs is to help the departments – really, the Department of Health in England – help them understand that if you're going to have a balanced scorecard it better be proper and balanced, and it better be reasonable and decent. We think the ones that most PCTs operate are drawn up by people who don't understand general practice. If they did they'd have different ideas.

Can LMCs fight them? No. So what you have to do is explain how to play the game. It's not the first time GPs have had to play the game. The current rules say you've got to do x, y and z in order to do an OK practice, fine…

You think they should do x, y and z then?

They should find ways of presenting evidence that looks like they're doing x, y and z. GPs are past masters at turning their hand to whatever current set of rules are so there'll be a new set of rules. It doesn't matter if the rules are arbitrary or even mad. If that's what the rules are? OK.

So you can either work yourself up into a lather or you can see OK if this is what it is, we'll try to ameliorate it to make it sensible, and what we're left with we'll try and work on, to get all the local GPs to understand this set of arbitrary rules are what you're being judged by, so you might as well go away and have a think about how you fit into that if you can.

If the PCT are going to commission on the basis of this scorecard, commissioning primary care we're talking about, then you've got to make sure your practice looks OK. Many of the things are alright. Most of it's not completely barking – but there are some things within some of the scorecards that are a bit odd.

It's up to practices to work with LMCs to try to change them, or work with them, or ignore them, if they feel that's what they should do.

One of the areas you seem to be passionate about seems to be resolving the partner-salaried divide and ensuring there are enough opportunities to become partners…

Quite right – if they wish.

You've talked about various ideas including a return to something like the Medical Practices Committee, but there is a motion in the LMCs conference which says that despite the aspirations of the GPC, you haven't got very far. What's the plan going forward?

Well, they're quite right. It's very difficult in the current economic climate we find ourselves in now to persuade people to expand their practice. And it is remarkably difficult to do so, I'm not kidding myself.

But I think it's very important that we take these doctors off the streets, and give them proper jobs that they want to have. Pay them properly, with decent terms and conditions of service. And it's better to have them as partners than as sessional doctors, because it makes economic and operational sense. And we should be looking at how we do that.

So what's the plan for next year? More of the same. More encouragement, more cajoling, more reasons why you should do it. More involvement of sessional doctors in the GPC, if we can get them to participate.

There was some talk [in a Pulse report of a GPC meeting earlier this year] about seniority payments as a way in which you might be able to do this, to expand seniority payments to salaried GPs?

That was a private debate.

[At this point, we have to relocate. The interview continues a few minutes later…]

So, we were talking about seniority payments…

Yes, that was a private debate.

In more general terms, there are motions to the LMCs conference suggesting that salaried GPs could have seniority payments as well. Is that something that's not workable?

It's not workable in the way that some people think it is, but the idea of recognising experience is something that we will be happy to look at. I'm not sure what that means, I'm not sure how I'd operationalise that, but I'd certainly be willing to talk about it.

And not the Medical Practices Committee as such, but setting up an organisation similar to that, where are you at with that?

Well we've spoken to ministers about it, and we've spoken to NHS Employers and civil servants about it. They're not hostile, but they're not terribly interested either, because they can't see what the problem is. They say well you're independent businesses, why don't you just sort it out yourself? But the problem is workforce planning is something that this Government has damaged very badly – I don't just mean GP workforce planning but workforce planning in general - and I think it's really messed up.

I can't understand why a country this small doesn't have central workforce planning, that is just mad, and I believe we should do something about that. And the same applies to general practice as to the hospital sector. We have to have proper workforce planning with the right number in and the right number out, and we have to have not direction of labour, but certainly labour going in the places that labour needs to be, and we don't have that any more. We used to, and it worked very well. It was rigid, and a lot of practices were very frustrated with it, so I'm not pretending the MPC was loved by everybody because that's definitely not true, but they enabled wise decisions to be taken even if individual practices resented what they said, and I think that was a much more sensible way of planning a health service.

Could you ever see general practice become a totally salaried service?

Well, that's Labour party policy of course.

Is it really, I didn't know that.

Well I don't know if it's been rescinded, I don't think it's been rescinded, I think it's still policy. That doesn't mean they've done anything about making it happen.

Could I see it? I could see it. Yeah.

Does it worry you as a prospect?

As long as the salary's high enough, it doesn't worry me, no. Whenever I go anywhere and talk about this, I often do a poll, a show of hands. Who'd be salaried if the salary was big enough. And most people if the salary's big enough would be salaried. I'd be salaried if it was big enough.

There's nothing magic about being self-employed any more. I think 30 years ago there probably was, but now I don't think there is. I think the great benefits have gone. So I'm not sure I would be exhausting myself not to be salaried.

I think the independent contractor status is by far the best model of delivering general practice so I wouldn't welcome it, but if that's the only way general practice will survive, well OK. And I think we'll have all the disadvantages of that too.

Just a couple more areas to cover – revalidation. I think when I've heard you speak before you've said that revalidation has been on the cards for a very long time, do you think it might be further delayed?

No, I think it's now happening. It was first sort of approved by conference in 1992, so it's not exactly a new topic, and first approved in any meaningful, seriously detailed way in 1997, so it's been on the cards for 12 years.

Why has it taken so long?

Because these things take a long time. What's really shifted it was the GMC, that's what's shifted it. So I think it will be as good as it is resourced to be.

Most of the profession are behind it. They're bothered about the minutiae and the operational issues, but actually the idea, I don't think there's huge opposition to it. In fact I'm not aware of any opposition to it.

What's the mechanism going forward to work out how it's paid for?

Well, you're talking about for GPs… The RCGP will plan what recertification within the college looks like, and they will dovetail it with revalidation for the GMC, and we're obviously going to have a big say in that. But the critical say will be in how it will be resourced, how it's going to be made to work, who the responsible officers will be, how they're going to work.

There are so many questions and so many are unanswered.

So you're no closer to working out how it might be paid for?

No.

On the future of the QOF and the recent consultation, you were pleased not to have local QOFs going forward?

Yes, I think they're crazy.

How do you feel about this issue of public health outcomes targets being put in the QOF?

I think I'd need to see what they were. There are some public health things that I can actually influence but the vast majority I can't. And I don't think I should be held responsible for society's ills.

If it's something where GPs are directly implicated and can directly influence, that's OK. This is a thing for paying my staff, this is a device for getting expenses into the practice, and it can't be subject to societal impulse. It can't be.

Where are you at in terms of getting last year's DESs rolled over?

Yes we're trying to get them rolled over.

Do you know when you might be likely to reach agreement on that?

No, that's part of this year's negotiation.

When you're giving your speech to the LMCs conference next week, summarising the year and so on, there have been a few issues, extended hours, you mentioned the prevalence formula as well, where some people may feel the GPC has been beaten down by the Government in whatever way. Do you think you're holding your own in negotiations?

Those people who perceive it as an incessant war between us and them, between GPC and the Government, misinterpret what negotiations are all about. The health service never stands still, it's moving all the time. And our job is to make it work as best it can for doctors and patients.

I think some things have been good, some things have not been so good this year. We got a pay rise. That was good. It was very tiny. That wasn't so good. We got our expenses recognised for the first time in years. That was good. We didn't get very much for them. That was bad. So you win some you lose some.

QOF, it's been given to NICE, we didn't want that. But local QOFs have gone away. So, you know – I'm not complacent. I wouldn't walk around and say it's been the most terrific year of all time, because that's just not true. It could have been worse. That's not much of a consolation. There will be GPs who are poorer as a result of what's happened this year and I wouldn't blame any of them for being angry. Because I'd be angry, and I will be poorer, although not by as much as some other people.

You cannot go into medical politics and make political change with one eye on your own personal private wallet. You can't do that. And equally, although I can understand why ever individual GP looks at their own practice and their own income and their own way of being, you have to reflect on the fact that these are national negotiations, and even in local negotiations almost never is it just your own personal self-interest. Because it's LMC-wide, or region-wide, or something-wide. It isn't just me and the PCT chief exec having an argy-bargy and a toss up over how many whatevers there are.

In the end, you have to produce the maximum good for the maximum number of people. That means a minority will not benefit from what you've done. Either they won't get a pay rise, or something will change, or some adverse regulation will hit them differentially, and yeah, that's true. So I don't walk around complacent, I just think… the health service has moved forward without most GPs taking significant damage, and some GPs have earned more money. I should think most GPs have earned more money. Some GPs have earned a lot more money and some GPs have earned a very more modest amount more money.

You say the maximum benefit for the maximum number of GPs…

Yeah, that's my philosophy.

Do you think on balance, since you became GPC chair, taking everything into account, GPs are better off?

I think that's too complacent for me to answer that question. I think that would be cocky. Ask me ten years from now.

If you answer that question yes, that's "I've done very well". You could produce 300 GPs who said I haven't done very well.

And if I say well actually no, it's been a pretty pathetic show really, an awful lot of people will say well actually, I'm doing OK. So I don't think I'll answer that question. Ask me in ten years.

Dr Laurence Buckman: 'I'm never an optimist' Dr Laurence Buckman: 'I'm never an optimist'

Most people if the salary's big enough would be salaried. I'd be salaried if it was big enough.

We don't do personal. I don't believe in attacking individuals, they are carrying out Government policy.

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