In full: Jeremy Hunt's speech to the RCGP Conference
Thank you for inviting me this morning and for your work as GPs. The truth is that if general practice fails, the NHS fails. It’s as simple as that.
The evidence is that despite enormous pressure, you are continuing to deliver superb care. I think recent CQC survey came out confirming that nearly 90% practices are delivering good or outstanding care, that four in practices get lowest scores are improving on re-inspection.
The British Social Attitudes survey said GPs had 85% satisfaction rate – some of the highest rates in country. And evidence on the ground if look at it is there is some extraordinary innovation that is happening in places like Whitstable, or Modality, or Hurley Group. There are some really exciting things.
Pressures in general practice
But if we are going to have an honest conversation about challenges and pressures in GP practices we have to look at those pressures. We have to recognise that too many GPs are knackered, feel often at the end of their tether. They feel they are on a hamster wheel of 10-minute appointments, 30 to 40 every day, don’t feel able to care like to give to patients.
Increasing numbers are choosing to work part time and at worst to the leave profession. So we have to think hard about how to stop that happening if we are going to use the magic of general practice to do what need to do for NHS. That’s what I want to talk about, how we address those issues.
When I became health secretary five years ago – this is the third time I’ve come to conference – the usual conversations were about money.
Somebody said to me recently, there are only two things people want from Cabinet ministers – money and silence.
Of course money matters. But over last few years, with respect to the NHS, what I’ve learned is that, yes, money matters, but capacity matters massively too. If you don’t have doctors and nurses to spend money on, it is not going to work.
That is why, after I was reappointed to this job after the 2015 general election – the first of three times I have been reappointed - I announced our plan to recruit 5,000 extra doctors to work in general practice. To be absolutely clear, that is a net target – we are talking about increasing the size of the workforce from 34,000 to 39,000.
When I announced that, it was met with some enthusiasm and some scepticism. So I want to explain why that for me is a really important target. I think the type of work you’re doing has changed profoundly over last two decades. You are seeing a lot more patients with greater needs. That means the old model of ten-minute appointments doesn’t really work for patients with multiple long-term conditions who may need 30, 40, 50 minutes to get to the bottom of their needs.
And so many GPs are talking to me about the problems of burnout. In the end, there’s a mismatch between the work we are asking GPs to do and the number of GPs we have to do that work and that is the root cause of that burnout, and we absolutely need to address that.
There are also couple of strategic reasons why I wanted to give GPs the biggest proportional increase of any major chunk of NHS workforce – indeed, the biggest proportional increase in the history of the NHS.
Because if the health system is sustainable, like health systems all over the world, we have to move to a model where we value prevention as much as cure. GPs are on the front line of that transformation. It is the whole thinking behind the whole Five Year Forward View, STPs. We’re just not going to be able to deliver that profound change in culture unless we back our GP workforce to do what we need them to do.
Continuity of care
I’m not a doctor - I can only speak as a patient. For me, the best thing about the NHS is having a doctor who knows you and your family. Continuity of care is incredibly important. It’s why patients values GPs and love the NHS.
People from health systems all over world who don’t have the developed primary care networks that we have, who don’t have continuity of care are asking how they can set those systems up.
You tell me continuity of care matters for professional reasons as well. As GPs you are generalists and you are having to make judgements – principally how ill someone is and whether they need hospital treatment. Knowing the context of someone’s value, circumstances - indeed knowing other people in their family - can be helpful in making those judgements.
The truth is, because we have underinvested in general practice over decades, we have made it much harder for you to deliver continuity of care. That is part of the magic care of general practice, and I want to turn that around. I recognise we cannot do that unless we get more capacity in the system. So that’s why we stuck with our plan to get 5,000 more doctors to work in general practice.
I want to look at how we are doing. The truth is, it’s a mixed picture.
Let’s start with the good news. We said we needed to significantly increase the number of medical school graduates who are going into medical school practice to around 3,250 a year – that’s about half of all medical school graduates.
As you can see, we are doing pretty well. The numbers of medical school graduates going into general practice are up 9% since 2015. We are 41 higher than we were at this stage last year. We have 518 to go to get us up to the 3,250 mark.
We are reasonably confident we will do that, but there will be hard work. But this has been greatly to the credit of Health Education England.
But we are not stopping there. A year ago, I announced we needed a 25% increase in the number of medical school places. We are not just saying we want 1,500 medical school graduates every year. We are saying we need those graduates to go into general practice and psychiatry in particular. So when we announced in the spring which proposals had been accepted for the remaining 1,000 of those places, one of the key criteria were how good those courses are at training people for general practice and community work.
That has been relatively successful. However, we recognise it takes time to get people through medical school.
[Cough from the audience]. Every time I hear someone coughing I think about last week’s Conservative Party Conference! There are a few doctors here, so I should be ok.
There is a time lag before these graduates come through general practice. So in order to breach that gap, we’re going to need to do some international recruitment. NHS England have announced plans to recruit 2,000 GPs internationally.
We are going to focus initially on EEA/EU countries as their qualifications are recognised by the GMC. NHS England are going to open an international recruitment office for the first time next month. We already have 601 applications approved, which is an encouraging start.
We’re also going to look at our non-EEA recruitment to see if there is anything to reduce the bureaucracy associated with people wanting to come to the NHS from further afield. That is also encouraging.
GPs leaving the profession
But let’s look at where things have been less encouraging. Since we announced that initiative, we have also seen a disappointing increase in the number of GPs who want to leave the profession. In fact, the number of GPs who want to leave the profession is at the highest level it has been since 1998.
If you look at the GPs aged 50 and over, that equates to 7,000 GPs. We cannot afford to let that happen. We need those valuable skills from those highly experienced professionals. They have an enormous amount to contribute to the NHS. That is a cause of great concern.
We also have the issue of geographical diversity. There are parts of the country that are particularly under-doctored, and there are other parts of the country where it is hard to attract trainees. There are some parts of the country like the West Midlands, Humberside and East Kent that score badly on both counts. So we need to look at that.
Those are the challenges. The question is how we address those challenges. Let’s start with funding. The message you gave me two years ago was two-fold. You wanted an inspiring vision of general practice, but you needed that backed with the cash.
The proportion of NHS funding going into general practice fell in the first two years of my governance – it had been falling since 2005 – but since then it has increased from 8% to just under 10%, which is the highest proportion for a decade. And as we get to 2020/21, it is getting towards the highest ever proportion.
In terms of real-terms cash, that has gone up for four years in a row.
But I know it doesn’t feel like that on the ground. So let me give some examples of where money is going: £30m into the Time to Care programme; another £30m to keeping down your indemnity costs; we have now nearly 400 clinical pharmacists operating in practices; and £20m on practice resilience and vulnerable practices.
But I think the heart of the reason you don’t feel that is because the pressures have been increasing at the same time, and at a faster rate. That is why we have to look at capacity. We have spoken about the capacity in terms of GPs. The support staff also matters. Our ambition is not just GPs, it is 5,000 support staff.
We talked about 3,000 mental health therapists, 1,500 clinical pharmacists, 1,000 physician associates. We have so far seen an increase of 2,700 non-GP practice staff since September 2015, so we are more than halfway towards our target, which is encouraging.
But we also have to look at the question of burnout. This is something in which I need your help. There are things you can do in your individual practices. If you look at our pilots in 20 CCGs of our Time to Care programme, we are seeing some encouraging results. The heart of that programme is to try and look at the 26% of GP appointments that GPs themselves say are potentially avoidable.
If you look at the ten high impact actions, active signposting for example can reduce avoidable appointments by up to 15%. Up to 10% of appointments can be diverted to pharmacists. Online consultations can resolve 60%-80% of appointments.
In practices that have tried this have found they can release 45 to 60 minutes per GP per day.
For our patients that is very important as it means you have more time to spend with the most vulnerable patients and you have the energy to do your jobs.
In terms of the optimism quotient – which is not always high in general practice – before the programme 12% of practices were optimistic they could cope with their workload over the next year. That increased to 73% after the programme. So we want to roll this out and we think it’ll make a big difference.
There are other things we can do. The first is that we are making a lot of progress in terms of technology. We know that booking appointments online can save surgeries time, as can ordering repeat prescriptions online. Next year, NHS England have promised that every patient can access their record online through their app, which will lead to a big increase in the number of people booking appointments and repeat prescriptions online. That will help reduce admin workload pressures.
In terms of recruiting in hard-to-recruit areas, we have been piloting a scheme giving a £20,000 salary supplement to trainee doctors to go to areas that have been unable to fill a place for three or more areas. We have offered 126 supplements, with an 86% success rate, so we are going to expand this to 200 doctors in places where it has been a nightmare to get new doctors in.
On top of that, when we make our decision as to which medical schools will expand, we aren’t just choosing places that will steer people in to general practice – we are going to favour schools that will send doctors to hard-to-recruit areas.
Another very big issue has been the cost of indemnity. We see it rising to £8,000 per GP. I have decided after lots of careful analysis that we need to introduce a state-backed scheme for general practice. This will take time to introduce. It will take 18 months. We need to negotiate with the medical defence organisations, we will negotiate with the BMA and we will introduce those discussions in this year’s GP contract discussions and we will need to finalise it when we know the numbers in next year’s GP contract discussions so I hope the scheme will start in April 2019.
The intention in doing this is to have a scheme that is more affordable and reliable for you. The great advantage of a state-backed scheme is that we will have control of a number of variables that in the current system has caused indemnity costs to increase substantially. A number of people have said indemnity costs is one of the things tipping GPs on the verge of retirement into early retirement. I hope this will give some stability.
We will also be running pilots of the GP careers plus programme, which is a programme specifically designed to target GPs close to retirement who want to work flexibly, want to take mentoring roles and it has been extremely successful in Great Yarmouth and Somerset where we piloted it.
The other really important thing I want to announce is around physician associates. Many GPs have said it would be useful if they were able to do xrays, or prescribing. In order to do that they need to be regulated, so today I announce we will be consulting on the regulation of physician associates, meaning they could be much more useful. We need to be clear they are not replacing the work of GPs, they are working under the supervision of GPs.
Let me finish by saying this. There isn’t a silver bullet to the challenges facing general practice. But we do have a plan and we are implementing that plan. At the heart of that is not just an increase in funding but an increase in capacity. This is fundamental to the changes we need in the NHS.
The Commonwealth Fund rank us every few years against other countries. In July, they said for the second year running we were the best and safest health care system in the world. What were the reasons? They said we were the best in patient engagement and care planning. But who does the majority of that? It is our GPs. They said we were the best in the world for equity. But who are the people available for every section of society, whoever they are, see them free of charge? It is our GPs. And they said we were best in terms of access. Who are the people delivering 300m appointments every year? It’s our GPs.
So if we want our NHS to remain the best in the world, we have to back our GPs to do their job. And that is what I am determined to do. Thank you very much.