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At the heart of general practice since 1960

Interview: Dr Peter Swinyard, chair of the Family Doctor Association

An in-depth interview with Dr Peter Swinyard, the new head of the Family Doctor Association, on what Tory policies would mean for GPs, how to resolve the partner-salaried split - and why other GP organisations are ‘deeply boring’.

Steve Nowottny

An in-depth interview with Dr Peter Swinyard, the new head of the Family Doctor Association, on what Tory policies would mean for GPs, how to resolve the partner-salaried split - and why other GP organisations are ‘deeply boring'.

What do you believe is the single biggest issue facing the profession at the moment?

The danger of splitting the profession between partners and salaried doctors is a major concern. I know the GPC is struggling to try and prevent this, and they've set up a new sub-committee to try and do so. Clearly we're a much smaller organisation - we can't actually change the world. What we can do is try and provide the same sort of support for our salaried and sessional doctors as we do for our partners.

I think that we do have something to offer for sessional doctors, because it's not just the educational opportunities that we offer, but it's the feeling of comradeship. It's a hard thing to explain to someone who hasn't ever been to one of our events, but they're quite different to most GP events because they're actually quite fun. Most GP events are deeply boring, and most GP organisations are deeply boring. I won't name names – but one of them's next to the Iranian embassy and the other one is somewhere up near Tavistock Square – and they're just really boring organisations because they're so politically correct and they're so hidebound by conventions and committees.

We're a much leaner organisation. If you like, it's something like the difference between a very large practice and a singlehanded practice, in that we can make decisions remarkably quickly, because our structure is designed to be quick and efficient. We have a very efficient office in Lancashire where our chief executive works, and she's a fount of all knowledge about things general practice. And most practices, and doctors and practice managers, who phone up for advice will find that she can give them an answer straight away to her problem, or point them in the right direction to someone who can.

We're very good at solving and signposting. We have a chap called Phil Emmott, who used to be a PCT administrator and now works for us, and he's our Mr Regulations. And he actually understands all the GP regulations. I mean, I understand most of them because I've had the misfortune of reading most of them. I have one of these weakly retentive minds, and I can actually remember what's in the SFE and the GP regulations, and if I can't remember the detail I know where to look it up.

And sometimes we even have the opportunity to remind the Department of Health that they're advising us to breach regulations, as they did in a letter this week…

What was that letter?

They advised us to issue Med-3 certificates to people who had phoned the swine flu service, been spoken to by a spotty 16-year old in the call centre, and given Tamiflu. And then they ring us a week later and say they want a sick note. The Department of Health letter says that we can issue a sick note letter on that basis – whereas in fact that's against the regulations. I've written to the Department of Health today and asked them to clarify that, because clearly they are actually advising us to break regulations.

In some ways it's actually common sense, but then that's not a strong commodity at the Department, and it rather surprised me.

So this was a letter to GPs?

It was a letter to GPs, it was a circulated letter.

Was that sent in the last couple of weeks?

It came to me earlier this week.

It was just trying to get round the problem that exists, but without actually dealing with the problem properly.

I know I'm digressing from what you asked me but the proper problem is that we are increasingly doing consultations by phone, and it is not uncommon for us because we know our patients to be able to say, yes, Mrs Jones rang up, she clearly has exasperation of asthma, or chest infection, or whatever it happens to be, which we know is pole-axing her and making her unable to work. However we cannot actually write a certificate for her because we haven't actually examined her, which is what the regulations say we must do. And to some extent I get round by it by saying come and pick up the certificate and I'll wave at you down the corridor and that's just about an examination. But it's not very satisfactory. And I would much rather the regulations were changed to say we can issue a certificate if we have put ourselves into the position to make a decision, rather than actually physically examining a patient.

You were talking about the partner-salaried issue?

The partner-salaried issue is one which I think is going to run and run. One of the problems came up because of the new contract, and because different contractual models have different regulations in terms of employing salaried doctors. If you're a GMS practice, as my practice is, you have to use the BMA model contract, although I'm very sad to say that some people don't.

The BMA model contract is a good contract for salaried doctors, and gives quite considerable amounts of study leave and so on… In a smaller practice, that is considerably better than the conditions that most partners work under, and therefore it is less attractive for partners to employ a salaried doctor. I think we need to try and persuade partners that they should take on new partners in the traditional fashion, rather than salaried doctors, unless there is a specific need for a short period of time, or perhaps to take over maternity leave.

The big catch with employing salaried doctors which I think people are not always aware of is that if you employ a salaried doctor and then decide that actually you don't need that member of staff at all, and wish to make them redundant, their redundancy pay reflects the length of service not just with yourselves but with the whole of the health service. I think people get caught out on that, and they employ a salaried doctor who may be someone who has just come towards retiring, and decides to be salaried to have less responsibility for a while, and they employ this person who may be 60 or 64 years old, who has 35 years service, and then they make them redundant, because their practice shrinks for example, they then have to pay redundancy based on 35 year service. Which is a bank-breaker for many small practices, and very uncomfortable for larger practices.

APMS and PMS practices don't have to use the model contract, although they should, but they don't have to, and I'm afraid some APMS employers have a nasty reputation for exploiting salaried doctors. I meet a lot of salaried doctors because we have stands at PRIMED meetings and education meetings, where I play the drug rep and stand at the stand explaining what we have to offer, and a lot of salaried doctors come up to me and say I'm not employed on the BMA contract, I have to work ten sessions a week, I have to see 25 patients a session, and then I have to do all the paperwork, and I'm paid whatever it is, which is inadequate, certainly for the level of responsibility.

And I say, why don't you go somewhere else? And they have personal or family ties to that area, and are really very stuck. And I think it reflects very badly on those employers who do treat their salaried doctors as inferiors, and I think that is storing up big trouble. Anyone who treats their colleague as a servant is storing up enormous trouble not just for himself but for the profession.

You mentioned the model contract… there was a move among some in the GPC last year who were saying the way to make it more attractive to employers is to reform or moderate some of the terms in the contract. Is that something you'd support, particularly for smaller practices?

I'm a great believer in levelling upwards actually. I think the first positive step that the GPC really has to try and negotiate with the Government is to make is to make it compulsory for people in all contractual models to offer that as a minimum. And then that will become the minimum standard for employing salaried doctors. These salaried doctors are GPs like the rest of us, and because they choose the salaried option either because it's a choice or because there isn't a choice, doesn't mean they're any less good as GPs and doesn't mean they're any less well trained than people who are partners. And sometimes they're much younger, better-trained and cleverer than those of us who are partners.

Moving on slightly, something the Family Doctor Association has mentioned previously is the importance of marketing yourself and competing for patients and so on. Could you expand on that a bit and maybe talk about what practices need to do in terms of making themselves more competitive?

We run quite a lot of events on marketing and my predecessor as chairman Michael Taylor has written a series of papers on how to market your practice, which are actually wonderful and really well written. And as you know I talked at a marketing event for your seminar series.

The competition which we face nowadays in general practice is becoming increasingly intense, especially with the so-called Darzi centres. The days when I came into general practice 25 years ago nearly, when once you put your board up on the wall and said right I'm here as a doctor, and you had absolute security of tenure… if I think back to the late 1980s, even our list size was considered a state secret, and if anyone at the Family Practitioner Committee or Family Health Services Authority dared to mention our list size to a neighbouring practice, they very nearly got sacked for the offence of doing so. Nowadays everyone knows how many penicillin tablets I prescribe. It's a whole sea change in openness.

I'm a competitive business now. It's not good just thinking your list size will stay – it won't. Patients are more mobile, patients have much less fidelity to their practices, and if they don't like you, or if they think you haven't given them what they want, not necessarily what they need, they will go. They will go somewhere else where they can get it. In towns where there is a Darzi centre, patients are attracted by the idea of hot and cold running nurses from 8am to 8pm, they think this is wonderful to go and see a nurse on a Sunday afternoon or a doctor on a Sunday afternoon with an appointment. It suits some people.

The people it tends to suit are those people who we actually want to keep as our patients. They're if you like the inexpensive patients for us to service – the 35-year-old fit man – these are people we don't see, and I think they're people we need to market ourselves to.

And I think when we're talking about marketing the practice we've got to think about what it is that makes our patients want to stay with us, because it's much easier to keep the patients you've got than to attract new patients. Of course they're much cheaper for the practice. And then you've got to look at what would make patients at other local practices come and register with you, and patients who haven't registered at a practice come and register with you, patients who have just moved into the area. What would make them want to register with me rather than my competitor down the road? Is it convenience? Is it walking distance? Is it that someone's heard that I'm OK as a doctor – or that someone's heard that I'm not OK? Or is it that they like the surgery? Is it that I've got leather chairs in the waiting room for them to sit on rather than hard plastic ones? These are all the subtle bits that make people make a decision about where to go.

But I still think the most common reason that makes people choose a doctor is a recommendation from their neighbours, and the chatter in a shop and on the bus and even in the church in some areas, wherever people gather and talk about the doctors.

You mentioned the Darzi centres – they may be outliers, but we've reported in some areas, in Portsmouth, for example, that they have been really marketing themselves, with adverts in cinemas, or perhaps buses. Could you ever see us reach a point where normal GP surgeries are forced to do likewise?

Absolutely.

I don't want to be the Tesco's of general practice with great big banners everywhere. We've had the interesting experience - next door to my practice, there's a convenience shop, you have to get past it to get into my practice car park. And it was a one-stop shop, it's just become a little Tesco's. It's become a much better shop, and it's got a brand new shop-front, and the entrance to their car park has metal railings which actually belong to the council, and Tesco's have hung three big banners on it. They're very good at marketing, and we can learn an awful lot from how they do it.

Some people who live quite close to my practice I know do not know that my building is a surgery, or it hasn't occurred to them. So why haven't I actually put a big sign up saying The Phoenix Surgery, please come and register with us, because we would like to have a few more patients than we actually do. And we're actually looking at how we advertise our services to compete against our competitors.

It is just two miles into the town to the Darzi centre, and it will attract some patients, and we will inevitably lose some patients to it, so we need to maintain our business, we need to generate more income, more patients. I don't think we should be afraid of competing. I think if we work out what it is that we're good at and then sell it, I think we can probably do very well. But I think any practice that thinks it can sit back on its laurels and do what its always done will find that it's going to shrink, contract and die.

One of the slides I sometimes use for presentations shows a picture of a huntsman in full hunting pink, riding away from us on his horse – and the fox is sitting on the back of his saddle. The fox has adapted to the situation – and we have to adapt or die.

I don't practice the same sort of medicine I practiced in 1985 – I practice very much more complex medicine than I did in 1985. We have become the general physicians and that's as it should be, it makes the job much more interesting and much more fascinating. We're not just sorters of symptoms, we're actually people who care for patients in a very holistic fashion, and that makes it a very rewarding job to be doing. But I think that to protect ourselves as practices, especially smaller practices, from the competition – we need to have a large national identity.

This I think is one place where the Family Doctor Association comes in – that we have a very good and well-recognised brand. And if people can only realise that if they sell a brand people will understand what it means, and they don't have to go into the detail. I think it was Walls many years ago who said when they're advertising they sell the sizzle, not the sausage. We're selling the sizzle, because if people understand that if you've got our blue logo of the Family Doctor Association, it signifies a practice which is interested in holistic care, and they'll have their own doctor who they will recognise, that people will recognise them, and they're treated as a person rather than just next please.

I don't when I go to my doctor want to be patient number 1101372 who's a bit of a nuisance and comes in occasionally and wants something – I actually want to be known personally… You have I think when you're running a practice nowadays to think what is the entire patient experience, irrespective of any silly patient satisfaction questionnaires, which I think are hopeless and biased in the way they ask a question, and the way in which they select people to answer them.

For example the last ones that went out, they're all in English and they're quite long and quite complex, they are available in other languages. Unfortunately if you want to know they're available in other languages, that information is on the back page – in English. Which isn't helpful.

Not really, no…

Most of my new patients who come into my practice are either Turkish or Bengali speakers, as their first language. And to try and persuade them to fill in a satisfaction questionnaire, even if they are satisfied… and the evidence is that people from ethnic minorities are less satisfied with their doctors than people from the majority population, for whatever reason, and I don't understand the reasons, I think it's to do with expectations rather than delivery… I think that to try and gain patient satisfaction we have to say well look this is the brand of practice we're offering, and this is a better way of providing your healthcare.

Just because we're running smaller practices in our organisation doesn't mean we're providing a smaller service, and I think that more and more we are going to be encouraging people to join up and to federate and to use back room services from elsewhere. We're actually exploring at the moment ways of providing our member practices with back room HR accountancy, book-keeping, salary and payroll, all that sort of service, on a sort of contacted out basis.

Across the Family Doctor Association?

Across the Family Doctor Association. So a member practice can ring up and say look we've got to the stage of reorganising ourselves, our practice manager is retiring or leaving, and we feel we need to have another think about how we're actually organising ourselves. Or be even braver and say what we'd like to do is contract out these functions and make our practice manager redundant, and stop paying the salary of however many thousand pounds a year it is to the practice manager. And I think we will have an offering before too long which will actually be quite attractive to practices, and which will take away quite a lot of the headaches of the business of running the practice, leaving doctors to get on withw hat they're best at.

So that would effectively be like a very big federation?

It would, yes. It would be a sort of mixed up offering. So some practices would say well it's only payroll I can't get my head around, and some people would say I just want HR advice when I need it. And it's quite interesting - we've just done a survey to find out where people at present get their HR advice from, and it's a whole scattering of places, from just online advice services, to iQ practice manager software which is actually very good, which we offer through our association at a discount because it works and it's terrific – it's certainly saved me thousands of pounds – and as an aside we actually have people who we are linked with at the Family Doctor Association, some of them are corporate sponsors, some of them are not, who have offerings which we think are good and are beneficial to practices. We then say to our practices, look these guys are OK, you can use them without a worry because we've checked them out.

People like GP surveyors, who have twice now increased the amount that district valuers allow for the notional rent for my building – they have earned me about £18,000 in my personal pocket so far at no cost to myself – it's just great, they're providing a proper service. So we say to our members, look, these guys are OK. And we're very careful not to recommend people to our members unless we've checked them out to see they are OK.

We have an association with Lockharts Solicitors, and you don't get much better than Andrew Lockhart-Mirams in terms of legal advice in general practice…

You mentioned briefly the patient survey, and obviously there are lots of different ways of assessing GP practices that people are bringing in – two specific ones I'd be interested to get your views on, NHS Choices online patient ratings and also balanced scorecards.

Yes, those are two sides of a similar coin really aren't they.

Balanced scorecards can be useful for practices to look at what they're doing. My initial reaction I have to say when they were first brought in, was I think they were first brought in by some rather hostile PCTs in the Birmingham area, was that they were used as a weapon against GPs. I think the more constructive PCTs – and I'm lucky to work in an area where our PCT is by and large constructive - they can actually be a useful tool to see where you are doing reasonably well in certain fields, where you're not doing so well. I've just looked at our cervical smear rate, and compared us with neighbouring practices, and it isn't as good as neighbouring practices, so I went to our nurse and said why isn't it as good?

And it's clearly because we've had an open door policy for patients for a long time, and we have tended to get the non-English speaking and quite often Muslim women coming to us, who are very reluctant to have a smear done, more so than people of Caucasian origin. And so we've actually just got to work harder on that particular aspect.

So I think these things can flag up things that are useful, as long as you take them in perspective.

If you say OK well my balanced scorecard is great, and then ignore it, then you haven't actually gained anything from it. I think PCTs which are using them in a constructive fashion, where they're saying well on this you're doing really well but on that you're not doing quite so well, what support do you need to get it better, might end up with a really good relationship with their GPs. If you work together with your PCT then you always do better than if you try and work across each other all the time.

As far as the patient ratings on NHS Choices is concerned, again I think we have absolutely nothing to fear from that. The risk is always that it will be the disaffected few who take the time to have a moan on it, and to use it as a moaning shop, but it will very quickly become obvious to anyone who reads it with a half degree of intelligence that those who are having a moan are doing just that, and that those who've got something constructive to say will also go on the site and do something.

Whether it takes off or not depends on how interested people are in sitting at their computers rating this, that and the other thing all night, because let's face it you could rate everything. I shall actually be quite interested to see how it develops.

I think the way it is being introduced is very constructive, and I think that they have taken on board an awful lot of the concerns of GPs. I know that NHS Choices consulted us getting on a year ago, when they were starting to design the system, and asked for our advice on how to do it best so they didn't piss GPs off. They're certainly not in the business of doing so – they're actually in the business of helping provide information for patients, and helping practices provide the information they want for patients.

I certainly think that any practice that doesn't go on NHS Choices and update the automatic website you get from NHS Choices is really missing a trick, because it's not actually that difficult to do.

Is there a specific issue with singlehanded or small practices?

There is a specific issue there, because the NHS Choices doctor rating system is practice-based not doctor-based, and you can't through them make a comment about a specific doctor. Because if you have a single-handed practice and it's a comment about a doctor, it is a comment about the doctor… and likewise if it is a comment about a nurse it is a comment about the nurse, so it becomes a bit personal. And that's not the main aim of the NHS Choices site, so it isn't actually necessarily fit for purpose there.

But I think because the comments are all moderated the chances are that it will actually be OK.

And in all honesty they have a very open mind about it and if it ain't working, they'll pull it and they'll make it work and then they'll try it again. I think they're doing this incredibly responsibly.

Moving on to politics, we've obviously had the party conference recently – particularly with the Tory party, if there was to be a Conservative victory as looks likely in the general election next year, what do you think that would mean for GPs?

Well firstly, we're not a political organisation, so I won't express a preference for party politics.

We had Andrew Lansley talking at our conference a couple of weeks ago, and he painted a fascinating picture of life under a Conservative Government, for GPs, which is very, very challenging.

I think it will be potentially one of the biggest changes in my practice lifetime, in that practices will be given, my understanding is, budgets to look after all of their patients needs. Although he didn't specify it, I have a feeling that the development of that will be that the budget will actually include the cost of running the practice in due course.

So I think it is an enormous challenge. He said that each practice will be allowed to have its own budget for its patients, but will be allowed to lay off some of the high risk stuff back to the PCT at the practice's discretion. So for example, you wouldn't necessarily want to have the cost of complex oncology or renal transplant … the very high cost stuff which let's face it in a small practice it's very hard to risk manage that sort of thing because you may have one patient in three years who goes for one of these procedures, whereas in a large practice you may have three patients in one year, and can make a more reasonable averaged-out budget… So the options then would be for GPs either to say no I don't want to be responsible for those things, I'll hand the money back to the PCT for those things on an agreed basis and they can risk manage that over my practice and any other practices which have handed it back, and they'll take the loss or keep the profit as it were.

I think that the other thing he was quite clear about was that practices will sink or swim. He doesn't wish to preserve practices which are not capable of functioning in the brave new world. I think that none of us can be complacent about the fact that at the moment we have a business which is making us a decent living – and it won't always be the same.

I remember in the 1980s if a patient wanted to move practice without moving house they had to have the signature of the doctor to release them. And if you go back further, I found a patient's medical card from an insurance society in 1935 when they registered with me about 10 or 15 years ago – they'd been registered with the same practice ever since – and the rules for patients in those days were that you had to obey your doctor, you had to do nothing to retard your recovery, you could only contact him at certain civilised and stated hours, you must request a home visit before ten in the morning if you wished to have one, you mustn't contact the doctor after eight in the evening except in life-threatening emergencies, and any breach of the rules would be a subject to a fine not exceeding 10 shillings on the first offence and not exceeding 20 shillings on the second offence, which would also mean that you lost your right to any medical benefit for a period not exceeding 12 months.

So in other words if you don't observe the rules and piss your doctor off not only would you be fined probably more than a week's wages of the average working man… I mean can you imagine someone nowadays accepting they'd have a fine of £800 for upsetting their doctor and not be allowed to use a doctor for a year. In the modern context that just sounds extraordinary, doesn't it – but it's only seventy years ago.

Nowadays we're a consumer-driven society, we expect things to be available 24 hours a day. Our opening hours in our practice are considerably longer than they used to be. When I set up the practice in 1995 we had a half-day closed and we shut at lunchtimes. We're now not only open from 8am to 6.30pm five days a week, but we're also open to 8pm two days a week, and we're still steadfastly resisting opening at weekends.

Has something been lost do you think in those changes, in terms of the doctor-patient relationship?

I think what's a loss from my point of view as a GP is that no longer are we the only players in primary care. Patients do have choice, and they go to walk-in centres and see nurses, and they go to out-of-hours centres and see people who aren't related to the practice. And I think that although it was becoming unbearably hard work to look after patients 24 hours a day personally, I think the loss of doing so has been a significant loss. I think we have to just accept that has been a loss, and we have to move on.

Because we cannot go back to the days when we are 24 hours available. But when I started my practice single-handed in 1995 I was on call just me from April through to late August without a break at all. 24-7 I was on call. I couldn't leave Swindon. I couldn't go more than 5-10 miles away at all, see friends and relatives, it was just me. But, it was actually professionally very satisfying, because I had a very good relationship with my patients. If they rang up, I usually knew them personally, and a lot of things I could deal with over the phone….

A lot of things which now create an awful lot of work were dealt with very quickly and easily. I can't go back to working 24-7, I just can't, I'm too old…

Most GPs wouldn't want to, would they?

Most GPs wouldn't want to, you're right. But we have to recognise we've lost something a bit there. We've lost some little bit of the close relationship with our patients which was part of what made them trust us, because they knew we were always there for them.

The new way of working which as I say is a much more holistic treatment, and much more treating the whole person, and managing a lot of continuing chronic disease within our practice, is I think actually a better way of working. And I think that the quality of the work which we do is vastly better than it was ten or twenty years ago. I think the QOF has improved the quality of care for our patients beyond recognition.

That alone has been worth the introduction of the new contract.

Now we are miles ahead with diabetic care, and the United States, France, Italy, are lagging behind. In Italy, they say that they can't even get blood taken from their patients who are diabetic to check and see if they can control them or not – not only do we have blood taken from them, but they're actually quite well controlled.

I think that that sort of thing is a genuine benefit for our patients. What we've got to be avoid losing is the contact between the patient and their doctor, while recognising that sometimes patients come in to the practice to see one of my colleagues.

They've still got to know they can come and see the doctor, and I'm against having a ban on them seeing me for absolutely anything. I'm not there just to consult on complex illnesses, I'm there for people when they are uneasy with life, and they haven't got a diagnosis, or they've got some curious, odd symptoms. Or they're even coming in with something which seems fairly trivial, which in a triage-y fashion would be dealt with by a nurse somewhere. Often these trivial symptoms are door-openers so they can actually come in and tell me what they wanted to tell me. And I think we forget that sort of thing at our peril, and our patients' loss.

Someone actually came in to see me, he's a chap who almost never does, he's in his fifties, that was strange enough to make my antennae pick up a bit. He showed me a slightly sore knuckle, which was neither here nor there, and I patted him on the head and said there there, and then as he had his hand on the door, he said, on the way out, he asked me if it was normal to start getting up to wee an awful lot in the night. He came out with some quite prostatic symptoms, and I got him back in again, and he clearly had prostate cancer. And if he hadn't actually just come in with an excuse he would never have come in at all. So you've got to allow people to come in for anything, and not hav

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