1. Dr Chaand Nagpaul
The country’s most influential GP
Dr Chaand Nagpaul is late. And is currently bounding up a flight of stairs at BMA House to meet me, I am told by his press person.
He arrives, slightly breathless but visibly energised. And it is this vigour that has marked his past 12 months as GPC chair.
Whether it was telling the health secretary to ‘get real’ in a barn-storming speech the LMCs Conference, or persuading the Daily Mail to run a front-page story showing a third of GPs intend to retire just before the election, Dr Nagpaul has shown real grit and stamina this year.
But he faces major challenges. The health secretary is determined to make a name for himself by pressing ahead with his programme of greater scrutiny and seven-day working.
The devolved nations are going their own way on the GP contract and local commissioners in England have been given more power to break it up.
And many GPs do not feel that the BMA speaks for them any more. Other smaller pressure groups – such as the National Association of Sessional GPs, Resilient GP or GP Survival – have made waves this year, and sometimes left the BMA looking slow, flat-footed and irrelevant.
But Dr Nagpaul is none of those things. According to GPs who nominated him for the Power 50, he leads with ‘skill and diplomacy’, and has been a ‘great voice for general practice at a difficult time’.
And as Pulse sits down with Dr Nagpaul, he comes across very much as a man with great strength of purpose for the year ahead.
Congratulations on coming top of the Power 50. What are you proudest of this year?
CN: My proudest achievement has been representing the everyday GP to policy makers and Government. Our survey [of the pressures on GPs] was instrumental in getting, for the first time in a decade, new funding for GP premises. Because what we said to the Government was: ‘Forget about out of hospital care, what GPs cannot do is provide basic care’.
What are the next steps over the next year for your campaign?
CN: We have been successful in getting on the front page of a range of newspapers, which is mirroring the work that Pulse has been doing. And it’s been important to show the public why they may not have a good experience of general practice.
We’ve got to the point where - when I’m interviewed by the press - I’m no longer being told about how lazy we are, but in fact there seems to be an understanding now, for the first time, that general practice is under pressure.
And politicians and policymakers are saying the same. In his ‘new deal’ speech, health secretary Jeremy Hunt said that GPs are burnt out and we are under-resourced. The chief executive of NHS England publicly stated general practice has suffered systematic disinvestment for at least a decade.
So what we need to do now is throw those words back to them. This is the last chance to secure a foundation in general practice and, in doing so, securing a future for the NHS. So it really is a pivotal time that they need to put action to their words.
What are your main priorities for the next GP contract?
CN: What we want is some stability. We need to increase core funding in the contract and reduce micro-management.
[But] what’s more important is what’s not in the contract. We have one LMC that has estimated that 9.3% of appointments at GP practices in their area were a result of inappropriate demands: transferred care from other sectors; bureaucracy and filling in forms that they shouldn’t. So we need to stem that.
How can that be done if patients are told they have to see their GP or get a letter for this or that?
CN: There has to be – at government level – information given to the public on how to use general practice services responsibly. The Government did that for A&E – there were buses all over the country saying ‘say no to A&E’.
Part of that is about shaping demand and managing it, so one of the things I would do is totally overhaul NHS 111. Five million more patients were referred to GP practices by NHS 111 last year, many of whom should not have come our way.
At a local level, CCGs have a huge part to play in trying to stem inappropriate and unresourced workload. Thousands of appointments are being taken up for GPs simply to re-refer patients who have missed a hospital appointment or re-refer them to a specialty.
But also practices and GPs individually have a part to play. We produced our document ‘Quality First: Managing Workload’, because the profession needs to feel empowered and understand that it does have the ability to say no, in order to protect safe, quality services.
One thing you haven’t mentioned is seven-day access. Under what circumstances would you support this?
CN: We’re not entertaining the way in which the Government is implementing seven-day opening. We are saying we’re happy to have a discussion around some level of appropriate extended opening hours, especially within a networked arrangement.
That’s the response we have got from GPs on the ground, that this something they are not averse to looking at. But opening on a Sunday afternoon when there isn’t a need is something we would not be supporting.
Seven-day access has to be appropriately resourced and logistically possible. If you have an area that’s suffering recruitment problems, the priority should be to secure core general practice services, not divert those services into what could be seen as a luxury service. So we need to be sensitive about this, tailor it to local needs and not have a blanket approach.
In terms of the national contract, do you think GP practices should opt out if they can get better conditions locally?
CN: First of all, we’re not seeing large numbers of practices wanting to exit from the national contract. And it would not be right for a practice to exit from the QOF, to do more work for that money and then still be performance-managed on [their QOF performance]. And that’s what we’re seeing at the moment.
So is your advice to stick with the national contract because it’s going to get better?
CN: My advice would be that a local contract places practices to local vulnerability. We’ve seen that through the decade or so of PMS contracts and with APMS contracts.
It will be subject to key performance indicators, funding cuts and won’t have the protection of a national representative body. There have been innumerable examples over the last year where the GPC has been able to support practices where their local commissioning body has bent a contract rule to the point that it wasn’t fair. We’ve intervened and put things right. We don’t have that ability with local contracts.
But if you’re seeing increased workload every year and year-on-year pay cuts, can you blame GPs for wanting to go that way?
CN: I can understand why GPs are, as I am, unhappy, but I don’t think that local contracts will be the solution, any more than PMS was.
The biggest argument we’re making is that the Government has to redress this if only to fulfil its own manifesto pledges. It has to do something about resourcing general practice fairly and treating GPs fairly, which has not been the case in recent years.
Should you leave the DDRB process? It seems to be delivering pay cuts year on year.
CN: The DDRB process has, by its own admission, failed to translate our workload into proper resources.
One of the problems we’ve had in general practice is because of the capitation contract we’re working under. We don’t measure activity the way hospitals do, so we are this year trying to provide more information on the fact that GPs are delivering much more work.
It’s hard to say how it will pan out this year. Obviously if the DDRB system just doesn’t work for us year after year we’ll have to look at that, but we have tried different approaches.
Last year the DDRB’s recommendation was the same as for the rest of the NHS, but the problem was that the Government’s interpretation grossly underpriced expenses, resulting in what was an inadequate uplift for us.
Moving on, Pulse has campaigned on support for struggling practices, and there’s been talk of a rescue package – where it is at the moment?
CN: The new deal talked about a £10m support deal for struggling practices. We are talking with NHS England about a proactive approach to supporting the large numbers of GP practices that may not appear to be struggling, but beneath the surface have very fragile foundations.
We need to have a situation where practices can self-declare they are under pressure, and that will not be met with the threat of a breach notice or a CQC inspection. Before it reaches a point of services being affected significantly, there is a local taskforce or resilience team that can provide support to the practice.
It sounds like a no-brainer to me.
CN: It is a no-brainer! It costs so much more to pick up the pieces when practices start to collapse. Much more.
What’s your impression of the 10-point plan to boost the number of GPs? Is it enough?
CN: The 10-point plan was always going to kick-start some ideas, [but] it was never going to be a panacea. We have introduced a system to allow GPs to return to work after a career break, there are now some pilots of pharmacists working in general practice, so it’s doing what it can.
But, ultimately there’s only one thing that will improve retention and recruitment, and that is for the job to sell itself. You can’t just put glossy adverts up for general practice because that’s a very empty way of trying to sell general practice.
No one sold it to me. I actually walked into a GP surgery as a medical student and was impressed by the work, the holistic nature. The workload was manageable, it was rewarding. There were no adverts for general practice but the job was attractive.
Are you concerned there’s a move towards having a cheaper workforce in practices? Are you worried that might be a replacement for the 5,000 GPs?
CN: We need many more than 5,000 GPs because those GPs would barely enable us to stand still, let alone cope with the Government’s ambitions for moving swathes of care out of hospitals.
But whichever way we look at it, we do need to find ways of GP workload being supported by other professionals. Even if we wanted 5,000 more GPs, they are not going to appear tomorrow, so while we have a workforce crisis, we have to look for other ways to keep general practice afloat.
Pharmacists can play a part, but what I’m absolutely clear on is that none of these other skill-mix approaches is a substitute for GPs. They are to add and complement the GP workforce and provide that additional support in order for GPs to have a manageable workload.
Is it hard to balance saying strident things in public and getting heard behind closed doors with policymakers?
CN: It’s obviously always a balance. But what I’ve tried to do with the Government – from the Secretary of State right through to civil servants and NHS England – is explain to them that I’m not exaggerating the plight of general practice. It’s there in front of their eyes to see. It’s a very heartfelt message, as opposed to an antagonistic message; it’s there to help them address the problem.
Jeremy Hunt’s ‘new deal’ after the election disappointed many GPs. Do you think he needs to go?
CN: I think what’s important is the policies. We need to make sure that what we see now is a proper deal for general practice because the announcement previously didn’t offer any support.
What we need to do now – what I am doing – is to go back to the Government and say: ‘You have stated explicitly that general practice needs resources. Let’s forget about everything else and talk about how we address that, because unless you have a secure foundation in general practice, there’s absolutely no point talking about doing anything more.’
That’s what I want to bring to table in our dialogue in the coming months.