LMCs Conference 2012: Dr Laurence Buckman's speech
Read the full speech from GPC chair Dr Laurence Buckman
Madam Chairman, Conference
This is the fifth year that I have been privileged to stand in front of you as GPC chairman, and each year we have had to consider something new and terrible, devised by whichever government is in power. Another unwise idea that threatens to waste money, or damage the way we provide care, or just burden us with yet more paperwork.
I would love to tell you that this year was different; that everything was great; that, actually, everything was so fantastic we didn't need a conference at all. But I can't.
Anyway Conference, where would the fun be in that?
Sadly, it would not be true either. Some of the threats this year aren't new. They are things we have been warning about for years, and things we have been working hard to try to either mitigate or stop. These are now just round the corner.
But, Conference, some good things have happened this year. A few rays of light in these dark days.
GP training is soon to be extended to four years. We have long believed that GP training should lengthen to cope with the ever-widening range that GPs are expected to cover and finally this has been accepted. The only struggle now is to find a way to fund and implement it. Being a GP is a great career and we want many young doctors to swell our ranks and join one of the most professionally rewarding parts of the NHS.
And, secondly, we turned 100. One hundred years ago the GPC and the LMCs came into existence to protect general practice and make sure it would always be a profession in which young doctors would aspire to work. One hundred years ago, GPs banded together in LMCs to fight what they saw as the injustice of an imposed insurance-based solution to delivering health care. They became part of the BMA and united to take on the government of the day. Eventually they came to an agreement and settled into a system that worked them very hard but gave them what was, in retrospect, a reasonable payment per patient. All of this before the NHS. One hundred years of weathering reform after reform, and we're still here, stronger than ever. Proof, if ever it were needed, of our enduring value.
Sadly, our longevity in the forefront of medical politics, and this significant enhancement to our professional education, are not enough to make up for what has been a very eventful year. A year full of events we don't like or think are a waste of time, money and effort. As the NHS in all four countries lurches towards the buffers of financial and operational meltdown, we find that instead of the clear thinking the NHS desperately needs right now, we have regulation, bullying micromanagement and dissipated effort. But many parts of the countries have good relations between GPs and NHS management structures, and we need to celebrate such good practice where we find it.
In the dying days of PCTs in England, where some are trying to impose their ‘visions' for the future that are mean-minded and unacceptable – we cannot let this go on. We are fed up hearing about other people's visions for our service. People who have visions need injections. I just want to stick to what patients and doctors think.
The government needs to stand by its word too. CCGs are "membership organisations" as we keep on being told, they are our creatures not just another version of the PCTs they replace. GPs should be telling them what to do, not the other way round. We were told it was going to be different. I do not have to sign up to a set of rules hastily agreed by a group of colleagues pressurised to deliver my unconditional support. The government needs to make it so.
As I sit at my desk doing my "Gordon Brown Memorial Night Surgery", I reflect that I am doing this for no more money, and I am still told that GP access is poor. I am tired of the daily message that GPs are bad at something. Most patients say that most GPs are good at most things. Perhaps the politicians might acknowledge that occasionally. It wouldn't harm them, unlike what they have done to our NHS, which is slowly harming me.
After a tortuous passage through the Westminster Parliament, the Health and Social Care Act is now the law in England. GPC took a position of critical engagement with the whole enterprise until it became clear that there was no way that we could persuade the government to listen to the vast majority of GPs who see the idea of GP commissioning as a reasonable bet. Those GPs see the insistence of ministers that the NHS had to spend its energy competing with the private sector as odious. The BMA was already awake to the potential problems from the time of publication of the white paper and devoted considerable resources to lobbying on the bill, briefing and meeting MPs and peers as well as encouraging others to join forces with us to get the Government to listen to the chorus of concern. We publicised our views widely and a good number of our suggested amendments were taken on board. I understand that there are those who are disappointed that we did not stop the bill but we cannot do that in a democracy. The BMA position was well known in the media and in parliament but, as usual, the government found a way to listen only to those who agreed with their policy.
Conference, make no mistake: this Act risks endangering the NHS in England. Even before it became law, changes were coming that have fragmented care. Now private organisations have the green light to pick off the best bits. Service reform so patients could get everything they need from the NHS in a one-stop shop was something we could all buy into. But under these reforms patients will be lucky if they can get it in five visits. Enforced procurement of practices through APMS, even though GPs could deliver care just as well through GMS or PMS – coming your way. Quality rewards that pay GPs to cut corners on services on cost grounds – coming your way. Micro-management of GPs' performance – coming your way.
You may think that all GPs are against all of this, but there are plenty of GPs running CCGs and we have to represent them too, as well as rein in anything they do that we think is wrong. GPC will continue to work with the GPs who are developing CCGs because that is the only way to influence what CCGs will become. CCGs must be made to work with LMCs. This means that LMCs must not withdraw themselves
from engagement with CCGs. If this kind of pragmatic engagement upsets those who would have wished to stop the bill then I am sorry. GPC has to represent those who would change our NHS forever, as well as those who want it to stay as it is. GPC has to try to deter the potential for harm within CCGs whilst ensuring that GPs are democratically involved in CCGs, and LMCs are able to act as the voice of all GPs. That is the very reason why all GPs must be able to elect the boards of CCGs. Ordinary GPs must be there. We must be there.
LMCs must be at the forefront of every battle for the NHS, against every unwise attempt to make GPs do something outside their contracts, fighting for individual GPs against a system that makes PCT clusters dream up new and dubious ways to torture GPs and waste their practices' time. More reports that will sit on a shelf, more inspections and visits, less time to spend with patients. We want none of this.
So what will happen to the contract this year? If there is no money then do not ask us to do any more while our income keeps going down. There is almost nothing more to squeeze out of the contract so if something gets put in, something else has to come out. PMS contracts are well beyond their elastic limits and the Celtic versions of the NHS are struggling with their funding too. In future we may see PMS and GMS merge but not until everyone can work out how to pay for it, so I would not hold your breath. Dissecting who got paid what and which practices will cope with such a huge change will take a long time. Although Conference wants MPIG to go, and a better approach to fairer funding for GPs, we can only change what we have now when we have a rising tide of resources or else there will just be another load of winners and losers. I do not intend to do that to the majority of GPs without ensuring that there will be as few losers as possible.
As for the Celtic nations: their contracts are mainly the same as England, but will inevitably diverge as their politicians have different views to the English. It is the responsibility of GPC UK to prevent reductions in professional unity where we can, while encouraging national deals where appropriate. It is still true that what we have in common is much greater than our differences.
While we are getting our contract tidy, we will also need to sort out whose patient is whose. It used to be easy. Registered patient meant they were yours. Now we are threatened with registering patients anywhere. The pilot studies are currently underway. We know GPs think getting rid of practice boundaries is madness. We have accepted the need to pilot what ministers want and this became part of our negotiated settlement last year. Fortunately, the policy is not fixed but the pilot is. Just that. A trial to see if something all politicians want is possible. We think their version will destabilise practices for little benefit and ruin continuity of care and record. Let's see who is right. Needless to say, the Celts want none of this waste of taxpayers' money.
NHS 111. A good idea. One that could, if properly implemented, be of benefit to patients. Properly implemented. Why do I so often find myself cautioning that that is what is needed? Why is it that so many good ideas go bad because common sense doesn't prevail? We have been very vocal about our concerns about how this is rolling out, but at the moment a potentially dangerous version of NHS 111 is set to burst forth upon an unsuspecting public from April next year. Patients may end up
being sent to the wrong place, waiting longer, blocking A&E and using ambulances needlessly, when a little more consideration might make it all work properly. We have asked the Secretary of State to delay implementation until we can get this right and he has said he is thinking about it. That's not good enough. He needs to stop thinking and act. This change is too big and too important to be allowed to fail just because of some arbitrary deadline. Nobody sensible would change urgent care services this way, but the English NHS is forging ahead despite the risks.
CQC regulation will be with us this year as well as Revalidation. Another two things we agree with in principle, as long as they are properly implemented. The rhetoric mentions fairness, consistency of approach, being as unobtrusive as possible and easy for everyone to do. The reality? Despite the best efforts of the regulators, I fear it won't be like that at all. If we cannot persuade them otherwise, this will be another burden for GPs and practices. We have worked closely with CQC to get registration as simple as possible. We will do the same to get consistent training for compliance inspectors.
Appraisal is a different matter: A few PCOs are busy rewriting the rules without any reference to GMC guidance and a handful of overzealous Responsible Officers are damaging GPs' confidence in the process. Revalidation should not be confused with appraisal. The former is a process we agreed years ago, the latter is an evolving set of demands that some people insist can be altered unilaterally. What neither elements need is doctors asking a group of colleagues and staff whether we are safe. What do the enthusiasts for Multi Source Feedback think the replies will be? Is this really the only way to find out if doctors are any good? What a silly idea that will waste our time and money, whether we are being assessed or commenting on the performance of others. How are sessional GPs who move around going to get any of these questionnaires completed? Please. No more questionnaires to colleagues. It is one thing to ask patients' opinions, another to spend one's day filling in forms for other doctors, many of whom you may not know well enough to make that sort of judgement properly.
One thing that you can be certain of is that the GPC will be doing our best to ensure that it's not GPs that end up having to fund this. Both GMC and CQC want us to pay them for the privilege of being policed. Why should we pay to be regulated repeatedly? GPs are not small businesses that can raise funds by charging more. Given that we accept the need for better regulation, we should not have to pay for it as well. I will make sure we put this anomaly to the Pay Review Body.
While wanting to make us pay for regulation, governments seem remarkably unwilling to pay for better premises, something that many GPs desperately need and want if they are to really improve the services they can offer patients and really offer more care closer to home as the government wants. If they want us to do more that is presently done in hospitals, we need more space. And this will cost money. Either build proper premises and work out how to enable GPs to be part of the third party developer scene, or stop pretending that GPs can take on more work. We need funding to put GPs in areas where they are needed, so do not limit us by preventing us getting the funding to do so. General Practice is not like other services. The NHS needs us where the patients are, not just where banks and others are willing to offer loans.
When it comes to Sessional GPs they need to know that their work will be properly paid for and recognised. Especially as their numbers increase and their contribution to the NHS becomes even more important. As ever, our Sessional GP Committee, an integral part of the GPC structure, has been working hard on their behalf. I hope sessional GPs will find a new locum handbook out very soon useful.
Trainee GPs have at last got a most welcome one-year extension to training that will fit them for the future – assuming the NHS will pay them. The NHS needs to have a mature approach to workforce. It has ducked this so far, as the NHS has unwisely devolved everything to hospital-centric and GP-free Local Education and Training Boards in England. Sometimes you have to take central decisions with a thirty-year time-frame, not localised snap judgements with a lifespan of one parliament. GPs are retiring because not only are they are getting older, but the work is getting harder and the pension reforms are making those in their 50s rush for the exit. Trainee GPs see an uncertain future and go abroad, or take on short-term posts from which they can escape. Workforce problems need sophisticated solutions. Please, someone listen before we run out of GPs.
Almost finally, I come to our pensions. The government wants us to pay more, work longer and have a smaller pension. They will pay the price for this, whatever the outcome of the ballot. They have recklessly squandered GPs' goodwill. For a scheme that is in surplus, that was only sorted out four years ago, that was structured to give more money to lower paid NHS workers, to be thrown away so that we can all pay more to treasury as a tax – for that's what this is – is so wilful I cannot believe that anyone sensible would do it. Whatever GPs feel about this, I hope that BMA members will vote to give us a high turnout.
Finally, I want to thank three outstanding Scots – Mary Church our Chairman, and Dean Marshall SGPC Chairman and Mary's successor, as well as Hamish Meldrum our Chairman of BMA Council. They retire after this conference and they have left their mark on GPs everywhere. Mary and I worked on the new contract and especially QOF when quality meant something. Dean has been an invaluable UK colleague on matters of regulation, fairness of funding and vaccination policy, as well as leading SGPC so well. Hamish has left so many marks it is hard to know where to start – let's just say that his contribution has been immense and doctors of all types owe him, as well as Mary and Dean, an enormous debt of gratitude. As well as them, I want to thank GPC secretariat, our Legal, Press, Parliamentary and Health Policy departments for all the hard work they do on your behalf. GPC members, grass roots GPs all, have worked hard over the last year to deliver as much of last year's policy objectives as possible. I thank them all too.
Madam Chairman, Conference. These are tough, uncertain and not very happy times. This week we need to take the right decisions to set us on a more positive trajectory. We need to inspire hope when many GPs are nervous for the future. GPs are facing a host of unwelcome and unnecessary changes. They believe that their incomes cannot fall, nor their expenses rise any further before they and their practices become financially unstable. All of us can see that workloads are rising back to 1999 levels and most of us are back to 12-hour days. If we are continually ignored, we are going to be forced to walk away as our practices, our health and our
solvency fail. This is not a threat – merely recognising reality. This week is our opportunity to be heard. Let's hope someone is listening.
Conference, I move my report.