Dr Chaand Nagpaul's 2015 conference speech in full
The GPC calls on the CQC to abandon its ‘Oftsted-style’ ratings
I open this speech with a heavy heart, at a time when general practice is plunging into the depths of ever deepening pressures.
The triple whammy of morale, workload and workforce pressures I spoke about last year has become endemic. In September, the Health Education England Taskforce review officially declared a “GP crisis” –theirwords not ours- and the Centre for Workforce Intelligence stated that present GP numbers are “unsustainable…to meet current demand”. And the latest wave of applications for GP training schemes was even poorer than last year. The BMA’s biggest ever GP survey of over 15,000 GPs, signals a potential catastrophic timebomb ready to explode, with one in three GPs intending to retire in the next five years, and one in five GP trainees intending to leave the UK to work abroad.
It would be utter folly to dismiss this as scaremongering - the newly elected government must wake up to this alarming reality not only because it will fail dismally in its manifesto pledge for 5000 extra GPs, but crucially because unless it turns this around we won’t have a comprehensive general practice service in parts of the UK.
We’re fundamentally paying the price of years of government neglect and progressive disinvestment in general practice- plummeting from 11% of NHS spend to now less than 8, and with the proportion of NHS doctors who are GPs shrinking from 34% to 25%
To add insult to injury, many practices are also suffering brutal funding cuts from phasing out MPIG or PMS reviews, and often left hung out to dry. None of us could argue with fair funding between practices, but this crude robbing Peter to pay Paul from an utterly inadequate pot flies in the face of how the rest of the NHS is treated,
And this unashamed starvation of general practice has come as GPs have taken on the greatest growth in volume of care compared toanyother sector in the NHS, seeing an estimated 40 million more patients annually compared to 5 years ago, whilst A&E by contrast is seeing 600,000 more in the same period. And practice activity has equally rocketed with Northern Ireland data showing that the number of test results dealt with by practices increasing by 217% in a decade and administrative tasks by 115%.
The irrefutable fact is that demand has absolutelyoutstripped our capacity, and we simply don’t have the GPs, appointments, staff or space to meet these escalating demands. And it’ll get worse - the demographic change of an ageing population will add further workload, with an estimated 1 million more patients who’ll have three or more long-term conditions in a decade by 2018. And the explicit pan-UK policy of moving swathes of care out of hospitals onto an impoverished general practice landscape is a recipe for it imploding under the strain, with already increasing numbers of burnt out GPs and practices handing back the keys to government.
Conference, this is not just a perfect storm, but an absolute hurricane.
And a hurricane that will destroy the whole fabric of the NHS if the government does not act swiftly, since if it’s foundation that’s general practice collapses, everything above it collapses too
The maths speak for themselves. 16 times more patients will visit their GP surgery today compared to the numbers who’ll attend A&E. Each practice closure, each unfilled GP vacancy, each GP working fewer sessions due to stress or each retiring early willhugely reduce GP appointment capacity and a mere 6% reduction in patients seen in general practice would double the numbers attending casualty if they went there instead, and we could be talking not of a 4 hour wait but an 8 hour one. Saving general practice is indeed about saving the NHS.
GPC has worked tirelessly this past year to publicise this reality, and most recently through our massive GP survey highlighting the parlous state of general practice
There are signs at last that the message may be getting through. For the first time, we’re seeing press, TV and radio coverage about the pressures on GPs, as opposed to only attacking us, and with a semblance of public awareness that the crisis in the NHS is not only about hospitals, but also about the GP service that local communities depend on
GPC also forced the issue of the real elephant in the room of GP premises which had been totally airbrushed for the past 10 years. Our premises survey last summer, repeatedly quoted by Simon Stevens, showed that 4 out of 10 practice buildings are inadequate to provide essential care, and 7 out of 10 don’t have the space to expand services. Our contract agreement with NHS England finally secured a GP premises strategy, and this was instrumental in delivering the £1b infrastructure fund which will benefit over 1000 English practices this year..
GPC also secured agreement in our negotiations to address workforce pressures, and we’ve been key partners in the development of NHS England’s £10m 10 point workforce plan starting with the induction and refresher scheme providing dedicated funding and making it easier for GPs to return to work after a career break.
Last autumn’s five-year forward view in England was the first government endorsed publication explicitlyusing language of the under-funding of general practice, and a specificcommitment to transfer resources from secondary to primary-care, and to invest more in general practice itself.
In the pre-election manifestos for the first time it wasn’t just about hospitals, but all major parties nailing their colours to the mast to promote the central role of general practice in their future plans, and each trying to outbid the other in the thousands of extra GPs –not otherdoctors— that they planned to magic up.
And which takes us to today. Now the election is out of the way –I call upon the Prime Minister to jettison the political pipedreams of tomorrow and get real about how we resource, resuscitate and rebuild general practice today. It’s absolutely pointless promising 5000 extra GPs within this parliament if we lose 10,000 GPs retiring in the same period
Any New Deal for general practice must start with workload, workload, workload. In the 25 years I’ve been a GP, it’s never been tougher. I started out in general practice all those years ago with 24 hour responsibility, being on call nights and weekends– shackled to my bleep, visiting a patient at 3 in the morning and then back in surgery at 8.30 a.m. few hours later, and yes I also worked seven days. And yet it was easier then, more rewarding and manageable.
The current job has an unsustainable, punishing pace and intensity. We work flat out 12 to 14 hour days without a break, We manage complex patients often with four different chronic problems, trying to condense an hour’s worth in the impossibility of 10 minutes, given they were previously seen in four different hospital clinics of 15 min each. We look after seriously ill patients at home who would otherwise be in a hospital bed. We laboriously record a wealth of data on computer screens we’re performance managed on. Add to that the avalanche of phone consultations, hundreds of patient letters and test results daily, each of which could have significant consequences on a patient’s health, let alone the rigours of running a practice with increasing regulatory scrutiny and targets. Logic alone tells us we’re trying to square an impossible circle, and GPs are voting with their feet, with the BMA survey showing that excessive, inappropriate work and lack of time are the main reasons driving GPs out of the profession, leaving growing numbers of practices struggling with unfilled GP vacancies.
It’s no wonder that many younger doctors are shunning a career in general practice, since when they experience general practice in their training, far from the myths peddled of lazy GPs working office hours, they see the diametric opposite of doctors overwhelmed from open ended demand, working longer hours than many hospital shifts, and taking work and worries home with them at night and weekends.
But there’s a serious undertone to this. If we carry on the way we are, we’re putting not only ourselves but our patients at risk of care that is lacking in quality and potentially unsafe.
And in keeping with my duty of candour, let me today on behalf of the profession blow the whistle that 9 out of 10 GPs state that workload pressures are damaging quality patient care and the new government needs to take responsibility to put this right.
It should start by putting an end to general practice being a one-way valve of workload shift and the backstop for every problem in the NHS and beyond. Today several thousand patients will attend a GP surgery purely for the bureaucracy of the GP re-referring them the minute they miss a hospital appointment, or chase up a test result requested by another clinician, fill in school absence reports, provide sickness certificates, prescribe medication outside a GP’s competence because of hospital budgetary rules, or re-refer a patient to a related specialty because of Trust policy. I could go on. This results in longer waits to see a GP, since these thousands of appointments are not available for the sick patients who need to see us.
It’s unacceptable that our goodwill is being exploited in this way, by piling on limitless work onto GPs without any additional funding, while other parts of the system are paid for every ounce of activity. Resources mustfollow where care is delivered, and this mustbe a non-negotiable commissioning principle.
And this is precisely why GPC produced our toolkit Quality first: managing workload to deliver safe patient careand which is in your conference packs. It reiterates that in spite of all these pressures, the safe provision of care to patients mustremain GPs’ overriding priority.
After years of being browbeaten, we mustresurrect some empowerment - wedohave some control in the way our surgeries run and what work we take on, and as individuals we canexercise choices to do the right thing. That means stemming work that’s inappropriate, underfunded and above our capacity, if it’s jeopardising our ability to fulfil our professional duty of care for patients.
Our guidance has a range of templates to send to commissioners, providers and other agenciesin order to challenge inappropriate demands on our time. LMCs are key in in coordinating local strategies, and in England GPsmustexercise their rights as CCG members to hold their Board to account to use their commissioning levers to address this, and I’ve personally written to all CCGs Chairs accordingly
And the government must halt it surreal obsession for practices to open seven days when there aren’t the GPs to even cope with current demands. It would damage quality care by spreading GPs so thinly, and replace continuity of care with impersonal shift-work, and will reduce our availability for older vulnerable patients.And given that government itself believes that the NHS is short of 5000 GPs, let’s not even have this conversation until and unless it’s created these extra GPs first
We also need honestyabout what’s affordable within a deficit NHS budget trying to save billions. This must be about managingdemand, notstoking itwith political profligacy which will take resources away from those that most need it. Nowhere in the world does anynation provide a state-funded routine GP service 8-8 seven days a week, and here our government is pretending we can do more than anyone else with fewer GPs per head than in Europe, while spending less on health compared to virtually all other comparable nations – so please please stop playing games…
Any New Deal must give us timefor quality care, with 9 in 10 GPs stating that the 10 min consultation is wholly inadequate. And if government wants earlier GP referral of suspected cancers, that won’t happen by setting crude targets, but only if GPs have time to listen and examine carefully to suspect the beguiling nature of sinister disease, and equally patients need timeto describe symptoms they may be worried about – you can’t achieve that in the pressurised conveyor belt system in which we’re forced to see patients
It must also end the punitive overregulation that’s suffocating general practice- amongst the top four reasons why GPs want to leave the profession. UK GPs are subject to more scrutiny, performance management, and targets than anyother nation studied by the Commonwealth Fund - and that’s even before the introduction of CQC. It begs the question why England is spending hundreds of millions of pounds on an inspection regime not felt necessary in Wales, Scotland and Northern Ireland. Practices live in fear and threat, with days taken away from caring for patients to prepare for and endure inspections. The problem is that CQC has mushroomed into an industry of flawed performance management. We managed to get rid of the shameful intelligent monitoring bands, but still have practice ratings without context and circumstance, and which misleads the public with crude proxies that demean the holistic care hard working GPs provide. CQC needs to go back to basics of keeping registration simple, abandon ratings and plough the millions saved into patient services instead.
And if you really want to assure quality then change the systems that force GPs to work in ways that compromise quality and safety. I suggest that CQC inspects the government, to see if it’s well led, caring, responsive, safe and effective. Check its policies and targets, interview its civil servants, look at its track record, and of course consider feedback – compare its 36% electoral support – to the 80% of patients who are satisfied with their GP - and then declare whether it’s outstanding, good, needs improvement or frankly inadequate. Because conference being caring, well led, and assuring quality starts from the top and government mustlead by example.
And the public deserve transparency from politicians that we have an overstretched and understaffed GP service, and the limits of what we can physically provide. Just as we’ve seen a publicity drive to use accident and emergency appropriately, we need a similar national drive to highlight the crippling pressures on GPs, and to signpost patients to use other services where appropriate and to empower patients with strategies of self-care..
This requires a completeoverhaul of NHS111, which last year referred 5 million more patients to general practice, clogging up our appointments, and with only 15% of patient managed with self-care compared to a 48% previously. This comes as no surprise with a system relying on computer algorithms - not clinicians - to give advice
A New Deal must be contingent on personalised continuity of care, and abolish the anathema of short-term commercial APMS contracts which run general practice by remote control, especially given recent evidence that such contracts offer poorer quality of care at scandalous expense.
Please spare us the arguments that this is about European competition law. If that’s the case then please just change the law in England to match that in Wales, Scotland and Northern Ireland to back the time-honoured system of general practice delivered by GPs running theirown practices and seeing theirpatients over decades: a model the rest of the world is now trying to emulate.
Conference, I return to our biggest challenge that we don’t have enough GP’s to meet current demand. We know that the Prime Minister doesn’t have a magic wand to conjure up his 5000 GPs tomorrow. We therefore face a stark choice to sink or swim. I told you last year that I fought to be a GP, and that it defines my life and values. I didn’t take on this job to watch my profession drown a death. Therefore we must have determination, fight and a survival instinct to swim and grab anylifeboat to stay afloat while we rebuild general practice. That means working with anyother health professional such as pharmacists who can support GPs in their daily work. We must equally be creative about new ways of working and using technology to ease pressures. We’ve made some suggestions in our Quality First document and GPC will be rolling out guidance on such measures in the coming months.
And we need a national programme of proactive support with dedicated resources for GPs and practices struggling under pressure right now - not after the event when practices are about to collapse. And at a volatile time when anypractice can be vulnerable, we need support - not threats or breach notices when practices can’t deliver due to circumstance.
We must also take control ourselvesby pulling together as a profession in our collective will for general practice to outlive the current storm. That’s why GPC is supporting LMCs to facilitate local GP provider networks and there are details in your conference packs. Networks shouldn’t just be about taking on care moving out of hospitals - they should at their core be about supporting practices to cope with escalating pressures in general practice itself - to facilitate collaboration, share resources, systems, services, staff and provide cross cover with the strong protecting the weak, knowing that each of us could be vulnerable tomorrow. We must create an environment of inclusivity and security, where allGPs have a sense of belonging and collective identity- and in keeping with our survey findings to offer GPs a range of career options from partnerships, salaried to freelance, and with paths for career progression. This professional unity is vitalto make the most of our GP workforce, so that we all feel we’re on the same side to safeguard our future and that of general practice, We know we can be transformational if given resources to work together as we proved in the past with GP out of hours cooperatives. Therefore I today call upon government to provide a national organisational fund to support GPs working at scale
Conference, we’re at a juncture when politicians and policymakers alike are espousing general practice as being central to the NHS’s future. We musthold them to their word and boldly stake our claim. I’m not going to government with a begging bowl asking for favours, but with confidence and self-belief that the NHS simply can’t survive without us, and to demand that GPs are finally given recognition, respect, and the resources to do our jobs providing holistic care for patients.
And simply talking up general practice with warm words won’t magically increase recruitment and retention - you need to make the job attractive, manageable and rewarding so that existing GPs wantto remain working, and younger doctors wantto become GPs. And this means politicians giving airplay not just to a few clinical leaders, but to see the world through the eyes of hardworking exhausted grassroots GPs who keep the NHS afloat daily, and who I’m most proud to represent
Conference, I want us to be able to tell the future generation of doctors that while general practice is currently at a low ebb, that it has a hopeful future as a regeneration zone and with a central commitment to invest in its renaissance, so that doctorswillwant to enter our great discipline as I and all of you did. Only then does the government have the faintest hope of turning the downward spiral of GP workforce into a positive one, and to safeguard the survival of our unique and proud family doctor service that communities depend on. Prime Minister you have no choice. GPs, patients and the electorate will hold you to account for nothing less.