The Big Interview with Dr Laurence Buckman: full transcript
Sofia Lind interviews GPC chair Dr Laurence Buckman on the impending 2013/14 GP contract imposition and what will be a tough year for GPs.
GPs are facing terms of the 2013/14 contract being imposed. Please could you tell us how we got to this position, why contract negotiations broke down?
‘We had reached an agreement with a part of the Government, which another part of the Government didn’t want and matters came to a sudden stop.’
Half of GPs responding to a Pulse survey thought the GPC’s representation of the profession in the matter had been poor. What would you say to these GPs?
‘I would say that 225 GPs responding to a positive request survey isn’t a very good test of opinion. I am sad that half of 225 respondents, who would naturally be negative in a survey, because the kind of survey it is. I am not surprised that there are a hundred GPs who don’t think the GPC performed very well. A hundred out of 46,000 is not bad going, I don’t draw any conclusion from that. Inevitably there will be people who think somehow it would be different. Before I was on the GPC I also thought that you could do it differently, but actually, ultimately the Government holds all the cards, and if the Government decides that anything will be the case then that’s how it will be. I am not sure what a good deal would look like. It’s always possible for governments to second-guess negotiations, indeed it is quite possible for them to conclude negotiations and then renege on everything they have agreed on, as has happened before. So I react with sadness to the fact that some GPs feel that way and I am not surprised. It is an inevitable feature that there will be people who are disappointed with what happened, I am disappointed. I don’t think we did a bad job but we did our job and if they’re disappointed, well, I agree with them.’
You did all that you could do?
‘You can always do better. I don’t think anyone should ever be complacent. Negotiation is not about complacency, it is about getting the best deal you can. Which may be not good enough, and on this occasion we felt that the imposition that the deal, well, the imposition that we were threatened with, was clearly not good enough and there was no way we could agree to that. That is the consequence of saying we are not prepared to talk about these things. If negotiations are conducted with a gun to your head, agree or else, well we won’t agree then.’
Now you have said you won’t be able to block this outright but now you’re working on damage limitation. How will you do that?
‘You can’t block what governments decide to do. There are many things that happen in societies that governments decide to do that I don’t agree with, or indeed that the vast majority of the population doesn’t agree with, but that doesn’t mean they don’t happen.’
‘Now what we have to do is make sure that GPs are as equipped as they can to cope with what is coming, that we can do our best to diminish the damage that the deal, as imposed, will put on doctors. I think an agreed negotiation might actually have been quite a fair deal but what we are now being threatened with is impossible to do, and I think many GPs will be very upset about it, as well as losing income. I don’t blame them for being angry. I am angry, why shouldn’t they be.’
So how are you planning to do damage limitation?
‘We will be doing a series of roadshows. We will be communicating with the profession. In due course we will be having a survey to find out what the profession thinks, about a whole variety of things. We will also be issuing quite detailed guidance on what this will mean for individual practices, as well as a general statement of how we think this will go.’
So do you think roadshows, how will that help the process, what is the plan there?
‘I think it is important that colleagues see the people who have negotiated and represented the profession, for quite a while, so they can ask questions and challenge what has happened. I think they should. The whole point is being seen, you don’t hide behind an email, you are out there talking to people, asking so what do you think of this then. I think the answer will be “not much”, and my job is to explain that to people. So I have to get out there and talk to as many of these 46,000 people as I can, I and my colleagues, to make sure that everybody is able to hear it directly, rather than filtered through any other media. It has to come from us.’
A contract imposition with such far-reaching consequences has not been done before, has it?
‘Gordon Brown imposed the extended hours surgeries, that we opposed. There have been previous threats to impose and a minister of state intervened, after realising what it could do… it has been an imposition before, it is not the first time.’
‘I think that our main job will be to help people understand what this will do to their practice incomes, practice organisation, their staffing levels, their take home pay. I think it is a lot to take in. These are major disturbing changes that are going to upset people a lot.’
The Pulse survey also showed that two thirds of GPs expect they will have to reduce their drawings as a result of the contract changes. What do you think?
‘I am surprised it was down to 75% (who would have to reduce partner drawings), I would have thought it was higher. It will cut my income fairly steeply. I think most GPs will see a significant drop in take home pay, unless they are going to start sacking staff, which I don’t believe many of them will wish to do. Some may end up doing it because they have no choice, but I think most people will avoid that very carefully. Most of us are already efficient, we have already got rid of any extraneous staff members, and any wasted staff hours, so anything you’re cutting now is what would have been essential staff. I don’t think I want to cut my nurses or any other important staff in my practice. Some people may feel they have to but I think that will be unfortunate.’
A significant number also said they would have to lay off salaried GPs.
‘I hope nobody gets rid of salaried GPs because they need them to deliver the work in order to make the profit, so I would discourage people from getting rid of doctors, but I suppose some people will have to do that, they’ll have no choice, but I would hope that nobody does that. Getting rid of professional staff, again they are the people who are your profit centres, so to get rid of those people seems perverse, but there may be practices that feel they have no choice. As for reducing services, it is inevitable, if you have no money coming into the practice, you will be reducing services. How do we cope, in England, with the loss of 150 QOF points? I don’t know how they are going to cope with it, or I know how I am going to cope with it, which is with extreme difficulty.’
What will the impact be on GPs?
‘It is going to make harder work. The new DESs, each of which are OK on their own, but if you add them together to everything else you say, hold on, I can’t possibly do this. What it means is, if I am not going to do some of the DESs because I physically can’t, then I must be losing money, because the money that funds the DESs is 150 QOF points shifted into these DESs. I think a lot of English GPs will see significant adverse cash movements, and I don’t have an answer to that except to say it is the same for me and it is not something I am pleased with, but where does one think one could have negotiated this away? We’ve spent five months negotiating something, that the Treasury felt was not enough punishment. So here we are, here’s enough punishment, and I think many GPs will feel very punished by it as well.’
And the financial impact?
‘We have said many times that the QOF changes alone will in an average practice with 6,000 patients loses you roughly £31,000, and we will enable individual practices to calculate exactly what that means, but that is a ballpark figure.’
That could translate to making a staff member redundant…
‘Clearly, £31,000 is a member of staff, if you choose to do that. Or you could be that more efficient and try and cope. Personally on a 12-hour day I don’t possibly see how I could work longer hours, I don’t wish to and I will take the hit in income, because I am surely not working any harder and I don’t understand why any GP would wish to work harder. Some will do, some will say no I will not take the hit in income, I will just have to work that much harder, but I think that’s quite a lot harder.’
So what is the danger if the Government forces GPs into taking cut to income? What could be the unintended consequences?
‘The obvious unintended consequence is that people won’t do the DESs that the Government so desperately wants them to do. And there is nothing wrong with them as individual DESs, if you look at them and their subject matter. You couldn’t argue with them over the idea of looking after people with dementia, I can’t argue with that, but of course if you translate it into I am going to shut the surgery for a week so I can see everybody with dementia, then that brings it home to the rest of the patients you’re just not seeing them. Or if I am now going to have to do blood pressure on healthy people over the age of 35, I’ll have a blood pressure week, to see completely healthy people over the age of 35 rather than see people who are ill, which of course is what I am meant to be doing.’
‘So I think that the unintended consequences are going to be reduced access, I think the DESs, some of them, they won’t fall flat, I am sure some people will do some of them somewhere, but I guess a lot of people will not take on all four DESs. I am not sure actually you could take on all four DESs. The workload of all four is very steep.’
Has it all become to political?
‘DESs were always political, that’s what they’re for. The QOF has now been interfered with once too many. The whole idea is that it is scientifically pure, decent, and they just chopped a little bit too hard. The NHS is political – the NHS exists primarily to get governments re-elected, that is what it is for. I know a lot of us think it is about healthcare but it is politically charged, so I am not surprised if politicians have sought to interfere with it one too many times.’
Almost a third of respondents in the Pulse survey said they expect they will take on none of the four new DESs proposed.
‘I think when practices see the details of what has been threatened, many of them will take on some of the stuff, but few of them will take on all of them because I don’t think they will be able to.’
‘Practices don’t know yet. I think before we know all the details, before the imposition is concluded, we have had our discussions with the Government and our response to the consultation, is over, I think that it is premature. And as I said, I think the survey is quite a microcosm of the profession, moreover they are people who positively responded to you and so you don’t know what the people who haven’t responded to you think, if they think the same way or not. So I think it is too early to tell. I might ask the same questions in a year and say “did you do these things?”, I think then you get a much more accurate impression of who has done what. I think many people will do some of it.’
So how can GPs prepare for the imposition?
‘They are going to find out fairly soon from us, in immense detail, what this means for them and their practices, and some of them will manage to cope with it all and I think a large number will be very upset by it, a lot of them will be very angry. They will be angry because they will say this is damaging my practice, including mine.’
You had always ruled out a strike on this matter, you have said boycotting commissioning would not be workable, are there any other routes of industrial action left or have you ruled that out entirely?
‘I think until we know exactly what the imposition is, I think judging what you could do, what you could threaten, bearing in mind that if you’re going to utter threats you’ve got to carry them out. So telling people that the only opportunity in years to have any control over the NHS for GPs, you are about to sacrifice by saying well it has nothing to do with commissioning. I am not sure what a threat that is when there are quite a few GPs who are desperate to do that. Admittedly I think the vast majority of GPs actually don’t care very much about CCGs, or commissioning, but those that do are unlikely to stop because the BMA told them they should. And if the majority decided to not take part in commissioning, well actually, they probably weren’t going to anyway. What threats would bother the Government? Some of us suspect that the Government may not actually mind terribly much if GPs did not take part in commissioning, so we may be playing into their hand by saying well then, we’ll stomp off the pitch and who would take over? Well it sure won’t be GPs. I am not sure I want to encourage that.’
‘CCGs potentially offer an opportunity for general practice. It may be that that opportunity is shrivelling as we speak, but whether that should be linked to our pay and conditions I am not sure. And I am not sure how many people would take the kind of action that would make that deliverable. There is no point in calling for industrial action, when nobody takes it. That really doesn’t do you any favours. So the main aim is to ameliorate the imposition, to make it as harmless as it possibly can be – probably not very – and then try to make life as good as it can for GPs. To suggest to them ways they can preserve their practices, their energy, their lifestyle, and everything else.’
So you have no issues with CCGs going forward now?
‘We have huge issues with some CCGs. CCGs vary from those that are close to their local medical committee, very much inclusive, involving everybody, I don’t think we have great issues with them. And at the other end we have some CCGs that are not very user friendly, not very close to GPs, not involving LMCs, indeed excluding them. Those CCGs are not going forward in a way that was ever intended by the Government, according to the Government anyway, and we’re trying to work with GPs in those areas to try to get the CCG to see sense that excluding GPs from commissioning, other than a few GPs, is not the way forward.’
Do you think those CCGs will be authorised with conditions?
‘I suspect some will, I don’t know yet, we’ll have to see who is authorised, what conditions they have and what they are before I will judge it. Some I am sure will have conditions imposed.’
2013 is going to be a big year for practices, they have to prepare for contract imposition, CCGs…
‘Well they’ve got that to prepare for as well as revalidation and CQC. That is enough to be getting on with. Having piloted a CQC visit I can tell you it wasn’t that bad really, but of course the Government is taking away 150 QOF points that pay for the work that goes into CQC registration, so that means you’ve got to do the work without getting the money for it, which I think is infuriating to put it mildly. But the actual visit wasn’t that difficult, filling the forms in wasn’t that difficult and I found the experience quite reasonable. I’ve been revalidated now, I can see that if you were a sessional doctor, especially a locum who moves around, I would see revalidation getting quite difficult, as the multi-source feedback forms are almost unusable if you’re a locum. For someone like me who stays in one place, it was OK. It was the same as an appraisal is, except I had to use an amazingly bulky piece of software. Well you just have to grit your teeth and cope with it, it took several hours to fill in.’
Did you find it to be expensive?
‘No I didn’t have to pay. I had to have somebody independent count up my form. It wasn’t expensive at all except you cost my time.’
‘But people are scared about these issues and when you add all this up, how you’re going to fit all this in, and then you have the imposition on top of that, and now suddenly it looks quite disturbing.’
And then there are pensions as well, which are changing…
‘Yes. Pensions I think are a background irritation. For younger doctors they are going to be a real intrusion into ones financial arrangements. I am of the generation that will be marginally annoyed by it, no more than that. But I think people ten years younger than me will suffer. And those 20 years younger will be questioning why they are becoming GPs. If the pension is going to be reduced. It doesn’t make it feel better to say, well of course, your pension is much better than a private pension. Yeah ok it is, but that is not why I went into the health service, for the pension, but I was told that my income was held down because I was going to get a good pension at the end of it, and now that is not true. Well for me it is sort of true. For younger doctors it will not be true.’
The pensions day of action didn’t force the hand of the government, do you regret orchestrating it?
‘I didn’t orchestrate it. I was a member of the BMA Council, I wasn’t an orchestrator, I was a doer, I was witnessed by a number of people action, which meant seeing patients. I’ve been threatened by my PCT cluster as a result for taking that day of action. It is always nice to have a threatening letter telling you “goodness knows what will happen if you ever take action again” but I don’t think I would take action on that basis again. No I don’t regret it, I think it was something we had to do and the Government are talking to BMA again about pensions, so did it work? I don’t know.’
Did the pensions day of action strengthen or weaken your hand in the contract negotiations?
‘I don’t think it made the slightest difference. It was about an unrelated matter, to do with all doctors, across all four countries about an issue which is hugely unfair in various regards, and it is a matter that we had to take action over.’
We have a new Secretary of State for health, have you noticed any difference in policy or tactics?
‘I have noticed no difference in policy or tactics. Obviously as human beings they’re completely different men. Both very pleasant as it happens. I haven’t had time to develop a relationship with Mr Hunt yet, I’ve met him a couple of times. Andrew Lansley and I worked together for five or six years so I clearly did know him quite well. I clearly don’t have the same chatty informality that I had with Andrew but of course I don’t know him well enough. In time maybe I will do. He seems a very nice man, it doesn’t mean his policies are any more acceptable. But I haven’t noticed a significant policy shift, no. He has some things he is more interested in. IT, dementia, some of those are things that come from No 10 or the Treasury, but he has his specific interests, which I think many doctors share as well so I don’t think it bodes well or ill that he has some interests that are different to Andrew Lansley.’
You have said that you will step down from negotiating in the summer. What you want to achieve before retiring?
‘I have to step down in July. I’ve done my six years as chairman and you can’t go on any longer. It’s time to go and you have to go while you’re ahead as well, and I will step down from the team because it is the right thing to do. What would I hope to achieve? I would have hoped to achieve a GP contract that has good clinical outcomes, that rewarded GPs well for what they did, that gave people an interesting time in their practices.’
‘I suppose I have succeeded in part. It is rather sad to be going at a time which is rather difficult for general practice. Would I have liked to stay on and get us out of this? Not really, I’ll be quite happy to let somebody else do it. It is always like this. When I was elected to office I said my job was to put my three drops of water on the granite, not to break the stone away. You can’t. This is too big a job for any individual to try and solve it. I think some GPs have the naive idea that if I go and thump the table hard enough somebody will wake up and listen and it’s not like that at all.’
‘I am proud of the QOF. I think some people’s lives were saved as a result of that. I was party to that. I think the new contract is better than the Red Book. Is it as good as it could be? No. Why isn’t it as good as it could be, because governments keep on interfering with it. I think the GPC is in a better democratic shape compared to before I came. Not because my predecessors weren’t democrats but because it is something that I have been working to push hard. Keeping the GPC relevant, interested and involved and connected closely to all local medical committees and to all GPs. I think I have been very much involved with communicating as much as I can with individual GPs as well as LMCs and the GPC.’
‘How would I like to go out? A world at peace is how I’d like to go out. At least an NHS at peace, but that won’t happen, so I’ll go out making a noise, like I always do.’