In full: GPC chair's opening speech to the 2014 LMCs conference
Dr Chaand Nagpaul warned in his opening speech to the LMCs Conference that the NHS was ‘in danger of collapsing’
Chairman, conference, colleagues.
I’m honoured to stand before you, for the very first time as Chair of the General Practitioners Committee, and to represent all 46,000 dedicated GPs working tirelessly across the UK, from partners, salaried, locum and trainee GPs.
Today, nearly a million patients will visit their GP surgery, that’s 16 times more than those who’ll attend Accident and Emergency units. UK general practice is truly the lifeblood of the NHS, its foundation and that which keeps the rest of the NHS afloat.
Yet this honour comes at a daunting time when general practice is in a parlous state, facing unprecedented challenges. I took office last July on the back of an imposed contract in England piling upon GPs a mountain of bureaucracy and unresourced work, and a summer of relentless media and political onslaught, scapegoating GPs for rises in A&E attendances to cancer mortality rates, linking it to GP opening hours, and preparing the political mood music for extended contractual access or personally providing out of hours care
Compared to when we met last year, we have today notably negotiated contracts across all four nations. In England, there was always the spectre of another imposition this year, from a government that had tasted blood once. Despite that, we negotiated hard to reverse most of the assault of last year’s imposition, but crucially with no change in contractual hours, or OOH working arrangements
So while months earlier the GPPAQ questionnaire or BP 140/90 target were non-negotiable, these and a raft of other imposed indicators have now disappeared. And while in England we’d never managed to get rid of a single QOF point without it being replaced by something harder, we’ve now moved 238 points into core funding. Three DESs imposed last year in risk profiling, remote care monitoring, and online patient access have all been scrapped with further resources moving into core budgets. We also reversed the imposed QOF threshold increases that would have commenced this April, and prevented the introduction of any new NICE QOF indicators. So on all counts we achieved significant U turns within months. And having paved the way in England, I’d like to congratulate the negotiating teams of the devolved nations in Wales, Scotland and Northern Ireland for achieving similar contractual improvements for their GPs
This was of course a negotiation, operating in the art of the possible, with give and take. The unplanned admissions enhanced service in England will certainly require work, but must be balanced against the significant tranche of bureaucracy and onerous work we’ve removed.
And while it’s right for GPs to proactively care for their most frail and ill patients, I’ve been absolutely clear to government that this enhanced service will not in itself achieve its aims unless the rest of the system plays its full part with coordinated health and social care services, from falls prevention, community nursing, rehab, home care and so on. This wider personalised care needs time and resources. Yet GPC’s initial findings show that only one in five CCG’s have made available the additional £5 per head resource promised by NHS England to practices. Therefore I’m forewarning government at this early stage that frail older patients will not receive the care they need until and unless this pronounced funding and community support becomes a reality.
But I also have no illusions. These contract changes, while a step forward, don’t address the fundamental issue of chronic underfunding and unsustainable pressures on UK general practice. We have the quadruple whammy of a crisis in workload, workforce, premises and morale. Last year’s GP worklife survey by Manchester University showed GPs suffering extreme levels of stress - the highest since records began, and a sharp rise in those intending to retire early. The government can’t argue with these findings, since they themselves commissioned this report, but conveniently fail to mention it anywhere. And what’s NHS England’s cure? To shamefully threaten withdrawing occupational health services for over-stressed GPs and their staff when they need them most.
And if, as some politicians and others claim, general practice really is such a jolly for overpaid GPs, then why but why are young doctors shunning it in favour of working in hospitals? We can’t recruit enough GP trainees to even match the government’s own target to sustain general practice, with the numbers of young doctors choosing to become GPs going down 15% last year. These doctors are not shunning the discipline of general practice, but the intolerable pressures that GPs are subject to, together with relentless attacks that devalue what we do, and which has butchered the joy and ability of GPs to properly care our patients.
Let me warn those that continue in their quest to denigrate us. Continue to put off younger doctors into becoming GPs, continue to accelerate those leaving the profession, and you certainly won’t have the last laugh when you won’t have a GP to turn to in times of need, and when the NHS collapses because its very building blocks have imploded.
But we won’t just roll over and let this happen. General practice matters too much to you and me, but more importantly to our patients who fundamentally depend on us. I decisively wanted to become a GP the day I set foot in an inner-city London practice as a medical student. I was awestruck by the enormity and breadth of knowledge and skill of my GP tutor, mixed with the sensitivity and continuity that being a GP is all about, as well as factoring the psychological and social context of his patients. To me this towered above anything I’d ever experienced in hospital. I entered a vocational training scheme in the late eighties when general practice was - incredulously - the most popular postgraduate specialty. I was one of two successful applicants out of 180. I was selected for a partnership out of 80 competing doctors, and where I’ve been a GP since for 24 years. So for me being a GP is an achievement, a privilege and source of deep pride, and I will not preside over the destruction of a discipline that like for you is my life, my vocation, and defines my values.
And amidst all the vilifying headlines and distorted anecdotes, I’d like to thank our greatest partners and allies - our patients, the overwhelming majority of whom continue in repeated surveys to express gratifying levels of satisfaction and most importantly trust in their GP- something that will always elude politicians and the commercial world that government is so in thrall of.
And whatever mud is slung, let us not forget that the sanctity of the interaction between GP and patient in the privacy of the consulting room has remained unchanged for decades. We’re let in to the world of our patients, confiding in us secrets not even known to their loved ones. Patients commonly delay an operation only because of wanting the approval of their GP first, who they trust to have their interests at heart as their advocates. It’s a privilege when we visit the abodes of our frail elderly when they need us in distress, with a touching reminder of their life history displayed on the mantelpiece. General practice remains a great job, indeed the best job in medicine. And it’s rooted in the trust that defines the GP patient relationship. Trust that cannot be taken for granted, and which once lost will not be regained. And which is why we must reject, oppose and challenge any system that threatens it, from perverse schemes that crudely incentivise GPs to deny patients care, systems that contaminate the consultation with conflicts of interest, or anything that threatens the confidentiality of the personal information that patients provide to us. And this is at the heart of why GPC called for a halt to care.data – because we want to ensure that patients trust the security of their personal information held by their GP, and what happens to it.
So what else needs to be done?
The immediate priority must be to protect those practices whose futures are at stake by imposed MPIG and PMS funding cuts. NHS England has flagrantly reneged on its assurance of national protection for outlying practices. The reality has been for practices to be left hung out to dry, at the mercy of pointless local negotiations with no funding, and without a thought as to the effect on patients. I have contacted several practices, looked at accounts and met MPs and it is shameful that patients will suffer at the hands of a formula that simply doesn’t capture the particular workload and patient needs in such practices. I have therefore this week written an open letter to Simon Stevens, Chief Executive NHS England, asking for an urgent meeting demanding that this unacceptable situation is addressed.
And the government doesn’t actually have to dig deep into its pockets to sort this –it paid 5 times the value of the total MPIG correction factor for a hospital winter crisis that didn’t even happen. And to add insult to injury NHS England plans to strip another £235 million PMS moneys out of GP budgets, money which should be used to support all practices to provide stretched essential services, rather than siphoning it off for new initiatives. And government must recognise that starving general practices of cash, is starving services for patients. And it’s patients who suffer.
We must then stem the relentless, unresourced work shifted into GP consulting rooms that overloads our ability to care. It’s indefensible to have a funding system that pays for every contact and procedure in other parts of the NHS, while taking advantage of the capitated GP contract by piling open-ended work onto practices to simply absorb without any new resources or capacity. This is unfair to patients who are subject to a pass the parcel experience that ends up in the GP surgery when the music stops. CCGs and commissioning bodies in the devolved nations must use their commissioning levers to make sure that when work is transferred out of hospital into general practice, that resources shift too, provided that GPs are willing and competent to provide that care.
And as for CCGs, we must restate that these are membership organisations. CCG boards must support member practices, who in turn should exercise their rights to hold their board to account. Yet initial findings from our CCG survey revealed that only one in eight GPs feels confident to challenge CCG decisions, whilst two-thirds feel their workload had increased. CCGs are not having it easy, but I urge them to park NHS England’s blue-sky five year plans for just a moment, and instead engage and involve all GPs, support them, and help them with their workload and not unwittingly add to it.
We then need time to care. The ten min consultation as a standard is an anachronism that should be consigned to the dustbin of history. Ten minutes is an insensitive insult to the needs of so many of our patients - those with long term, complex or mental health problems. GPs are forced into providing conveyor belt medicine at breakneck speed up to 60 times in a day. Add to this the sheer volume of phone calls, visits, repeat prescriptions, results, reports and hospital correspondence and we have an unmanageable, exhausting and unsustainable workload that puts safety and quality at risk, and is short-changing our patients daily.
We also need the physical space to care. With no national dedicated funding for GP premises in over a decade, we’re trying to provide 21st-century general practice from buildings belonging to a past era. Many practices don’t have the rooms for GPs to consult in, areas for patients to wait or staff to work, nor space to provide more services or train future GPs. So while CQC passes judgement on individual practices with inadequate premises, the elephant in the room is about actually providing the funds to make GP estate nationally fit for current and future needs, and this will be a key plank of GPC’s campaigning agenda this year.
But ultimately we need people to provide care, with 40 million more patient contacts per year than five years ago. The immediate priority must surely be to retain the current workforce, and stem the tide of early retirement, and GPs migrating overseas. As a start let’s resurrect the retainer scheme, and also remove the crazy hurdles that prevent many doctors from returning to general practice. And it’s only by making the job manageable, rewarding and in suitable premises that you stand a chance of improving recruitment. GP practices also badly need more staff - the nurses, healthcare assistants, receptionists and admin to deal with our escalating patient volumes. And we need expanded primary care teams built around the practice, with community nurses supporting GP’s in caring for our rapidly growing older population. This can all start now if the government commits to resources.
Politicians must also open their eyes to see that the crisis in the NHS isn’t only about four hour casualty waits, but also where 90% of patient contacts occur daily - in general practice. So while £500 million was given to ease the pressures in accident and emergency, it’s a kick in the teeth for general practice to receive £50 million not to ease any crisis or pressure, but actually to provide even more over seven days. The Challenge Fund could have been used as its name suggests, to address the real challenge of GPs struggling to cope in providing essential services for the needs of patients daily. And the opposition also appears blind to current pressures, and is failing to learn from the past, in resurrecting a discredited 48 hour access target, that will force GPs into offering perverse appointment systems that distort clinical priorities
Patients deserve better than this political gimmickry
And we must also dispel the myths that demean us. Firstly GPs have not opted out of anything. UK general practice serves the population 24/7 365 days a year, as it did before the 2004 contract, after 2004 and will continue to do so in the future. A patient in the UK needing a GP at 3 a.m can and will be able to see a GP. What has rightly changed, is that the GP visiting you at three in the morning won’t be the same GP who saw you at 3pm the day before. And it’s absolutely right to have put an end to GPs working throughout the day, night and weekends which was wholly unsafe for patients.
And while we’re fed the line that inadequate out of hours care is driving swathes of patients to casualty, the evidence shows the exact opposite. The Commonwealth Fund compared a range of out of hours systems across Europe, USA, Canada and Australasia, and showed that the UK had the fewest number of patients attending casualty due to lack of access to out of hours services.
But if you really want to improve things, then start with the first point of contact a patient makes out of hours which is a phone call to NHS 111. It’s a disgrace that patients have to endure a litany of questions from a computer algorithm about what they don’t suffer with, rather than what they do, with GPs receiving two pages of meaningless negative findings rather than why the patient actually sought help. Sort this out first, rather than diverting blame on other parts of the system. Patients should speak to a clinician at times of urgent medical need, not a lay person guided by electronic robotic questions that have no grasp of their complex, multiple or mental health issues
And let’s also put to bed once and for all the lie that GP opening hours are in any way related to A&E attendances. A fallacy quashed by a King’s fund analysis, which also showed that simply creating seven-day walk-in centres just increases demand and doesn’t reduce A&E pressures. There are 340m consultations in general practice annually compared to 21m in A&E. The truth is that GP practices manage demand on A&E, not the other way round. And if you destabilise general practice, it would only take us to see 6% fewer patients to double the numbers attending casualty if they went there instead.
Therefore we need to stand tall with confidence and pride, and not let attacks which are heavy on spite and light on evidence undermine our self worth. We must fight for our rightful recognition, for fair resources and valuing the greatness of UK general practice. And to remove obstacles that prevent GPs from doing their best for patients. And this is why we’ve launched our campaign telling the public and patients that “Your GP cares”. Cares about the fact that your care is being undermined, compromised, and devalued. And this campaign is not a one-hit wonder, but will be a sustained programme of activity. We’ve just launched an e-petition to government, and with a range of activities and publicity planned in Westminster to influence all parties in the run-up to the 2015 UK General Election. We’re providing practices with the tools and materials to involve your patients, and I’d like to remind politicians that 90% of the UK population will see their GP in the coming year.
But we also need an honest dialogue about how to use finite scant resources. It’s irresponsible in a climate of austerity to stoke up demand, raise expectations when there’s a requirement to save £30bn.
And the public must be told of trade-offs and that there are choices to be made, moral choices. Do you want GPs to spend more time providing personalised care to older frail patients in greatest need with multiple morbidity, or do you want GPs to spend time instead in their surgeries on Sunday afternoon waiting for healthier adults to walk in on the basis of convenience? You can’t have it both ways from a skeleton GP workforce that isn’t even coping with current demands. And nowhere in the developed world, where they spend much more than us on health, can they afford the luxury of a state funded routine GP service open 8-8 seven days a week.
And patients need be our partners in managing demand, through responsible use of GP services, as well as empowering them with appropriate self-care and management.
And I’m prepared to lead this debate with GPC launching a public consultation this autumn asking these precise, difficult but honest questions which politicians choose to ignore for electoral reasons
And when money’s tight, what does any business do? It invests in the most cost-effective tier to release cost efficiencies, and in the NHS that is undoubtedly general practice. GP practices are a bargain at the price- we receive just over £70 per patient annually– to provide unlimited consultations, home visits, phone calls, health advice, repeat prescriptions and so on for a whole year.
Contrast this with a typical tariff payment in England of about £150 for a patient to simply walk through the door of an outpatient clinic once.
Yet the direction of NHS spend is totally opposite. While huge tranches of care have moved
out of hospitals in the past two decades, it’s shameful that the number of GPs as a proportion of doctors in England has decreased from 34% to now 26% and the proportion of NHS spend on general practice has dwindled from 10% a decade ago to less than eight .
So after years of devaluing our worth, the crux of my argument to government since I took office, is for politicians to grasp that general practice is the solution, not the problem. That increasing the proportion of NHS spend into general practice by just an initial 2.5%, will translate to a one third increase in our resources and which could transform our ability to provide care that patients need, and reap huge cost efficiencies in a cash-strapped NHS.
And if Treasury is mistakenly paranoid about this being about GP pay, allow me to negotiate for resources to be directly used for more GPs, premises, nurses, staff and services, since the overwhelming priority for GPs is to have a manageable workload and tools and space to do their job of caring for patients. And resurrect the pride of being a GP that drew you, me and 46,000 others into our esteemed profession.
So in conclusion, I’m asking government to decide whether it wants a sustainable future NHS. And if so, the question is not whether it can afford to support, invest in and develop general practice? The real question is can it afford not to?