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Gold, incentives and meh

GPC chair: 'There is light ahead, a hope that we can rebuild general practice'

BMA GP committee chair Dr Richard Vautrey delivers his speech at the annual LMC conference, this year in Belfast

Last year, this conference called for the partnership model to be supported and sustained, demanded an uplift to the core contract to compensate for the changes related to GDPR and called for us in England to learn the lessons of the Scottish contract changes.

And these demands built on what you said to us in 2017, when we met in Edinburgh and called for a national indemnity scheme to remove the growing risk from GPs, and that GPC England should develop and agree with government a revised QOF that should be evidenced based and clinically relevant.

With major contract changes in Scotland and England....we have not flinched from the big challenges 

You wanted an end to annual contract tweaks and changes, you wanted a reduction in workload and an increase in workforce, you wanted us to enable practices to respond to the growing digital challenges, and above all, you wanted us to bring an end to over a decade of austerity, that has been so damaging for general practice and seen investment as a share of NHS spending fall at the same time the pressures on all of us grow.

I’m here to tell you now that we’ve listened, we’ve acted and we have delivered.

With major contract changes in Scotland, England and increasingly elsewhere in the UK, we have not flinched from the big challenges you set us but we have set about convincing governments across the UK of the urgent need to invest in general practice and community-based services, and to not just talk about it but to do it.

General practice is the bedrock of the NHS, and the NHS relies on it to survive and thrive. Not my words but the first line in GPC England’s contract agreement with NHS England.

“Our GPs are the bedrock of the NHS. They’re everyone’s first port of call. We need more of them, better supported, and better equipped. Prevention of ill health is nothing without primary care. So we back our nation’s GPs every step of the way.”  Not my words but those of the health secretary in England.

“It is only with the genuine involvement of GPs, as expert medical generalists, that we will be able to improve care for everyone in Scotland.” Not our words but those of Jeanne Freeman, cabinet secretary for health and sport.

Across the UK, in Cardiff, Holyrood, Westminster, and in Stormont (even without politicians), GPC UK is making and winning the argument for the GPs we all represent.

The challenges may be different, the solutions may vary, but they have one crucially important thing in common. We are all building on the solid foundation of the GMS contract, the partnership model and our independent contractor status.

As Nigel Watson’s excellent and timely independent partnership review has made clear the partnership model has underpinned general practice since before the establishment of the NHS, and it’s been a major component of its success since.

This 'NHS first' of preferentially investing in primary medical services is long overdue 

It embeds us in communities for the long term when other services come and go, it gives us the freedom to advocate for our patients, it enables us to innovate and respond quickly to change, and most of all it delivers continuity of care which saves peoples’ lives.

Thank you, Nigel, for stepping up and responding to the challenge set by government and NHS England, and for delivering back to them the clear case that the partnership model for general practice is far from finished but is worth building on and investing in.

In England, this has helped place general practice at the heart of NHS England’s long-term plan and with that deliver from government the commitment to a new guarantee that over the next five years, investment in primary medical and community services will grow faster than the overall NHS budget.

They described this as “an NHS first”, creating a ring-fenced fund worth at least an extra £4.5 billion a year in real terms by 2023/24.

We all know that, whilst welcome, the additional £20bn for the NHS is nowhere near enough to repair the damage done by a decade of austerity.

And we know too that without significant investment in social care, public health, and education and training, we will still struggle each and every day to meet patients’ reasonable expectations.

Rebuilding our services and responding to the growing needs of our patients will take a lot more, but this NHS first of preferentially investing in primary medical services is long overdue and in large part it is down to you, LMCs and GPs, empowering your GPCs to fight for general practice, and it’s a fight we are now winning.

In each nation though the challenges remain, and for far too many of us across the UK the problems created by practice premises are still a huge issue, and putting many doctors off becoming GPs in the first place.

In Scotland the agreed premises loan scheme has got underway and even been invested in further

Our major premises survey found that only half of practice premises were suitable for current needs and, most concerning of all, 80% of GPs didn’t believe that their premises could cope with future needs and population growth. How can we respond to the growing needs of our patients and an expanding multidisciplinary workforce if we don’t have practice premises fit for the future?

It’s good therefore that in Scotland the agreed premises loan scheme has got underway and even been invested in further as it is being taken up by so many practices. This shows what can be achieved when there is a real will to solve the problem. We now need the other governments in the UK to step up their support for practice premises.

In England we have other potential challenges and can still see the spectre of the integrated care provider (ICP) contract, a contract that rather than empowering practices could disempower them, and that rather than providing stability risks instability with the threat of wholesale private take-over.

Let’s be clear, no practice should feel pressured or bullied into joining an ICP.

With the development of primary care networks, built on the GMS contract, there is no justification for undermining this and the concept of ICPs should be confined to the history books even before they get off the drawing board.

In Northern Ireland GP-led federations are supporting practices through workforce expansion

Let’s instead build on what works, what has been tried and tested, and what delivers for our patients and the wider NHS. That’s what’s been done in Scotland, building the new contract changes around the expert generalist GP and their team, maintaining practices at the heart of their communities and supported by local health board services.

In Wales, whilst difficult negotiations progress, this means using the £100m transformation funding to strengthen and support primary care through practices working within clusters. And in Northern Ireland, even after two years without a government or health minister, GP-led federations are supporting practices through workforce expansion and leading the way with a pharmacist in every practice.

It’s vitally important to invest in practice baselines, but we also need investment in people.

Whilst the crisis in GP recruitment continues we need people working alongside us to shoulder the workload burden and help GPs focus on what we alone need to do.

GPs have always recognised and embraced the benefits of working with other healthcare professionals but now more than ever we are seeing practices, benefitting from the skills of pharmacists, physios, paramedics and social prescribers, all working alongside our nurses, healthcare assistants and experienced office and reception staff.

We’ve called for a reduction in our workload and that’s what we aim to achieve

We have called for a pharmacist in every practice and that’s what we are on the road to deliver. We’ve called for a reduction in our workload and that’s what we aim to achieve, and crucially, we’ve called for recurrent investment to make this sustainable and in England we’ve delivered over £2.8bn over the next five years to do just this.

General practice is a team game but the team does not stop at the practice doorway. Our team should include district nurses, health visitors, palliative care nurses, social workers, drug and alcohol therapists, occupational therapists and the list goes on.

They are people we should meet and know by name and not just be on the end of a redundant fax machine. If primary care networks are going to make a difference to our patients, we need to rebuild this wider primary healthcare team. We need to shape, and we need to lead, a reinvigorated primary healthcare team at the heart of every community.

As GPs we want to build services in the communities we work in and serve. We don’t want them undermined by “here today and who knows where tomorrow” digital services.

For NHS England to give the green light for GP at Hand to expand before the independent review simply beggars belief

And so, for Hammersmith and Fulham CCG and NHS England to give the green light for GP at Hand to expand their service across England using a remote base in London, even before the independent review that they commissioned has been produced, simply beggars belief.

We’re starting to tackle this by reducing the funding they receive through the English contract changes but more needs to be done to limit this abuse of the out of area regulations.

It’s why greater investment in IT for practices is so essential and once that’s done just watch GPs take the initiative. We need the deployment of broadband and IT infrastructure upgrades as soon as possible, for the best way to undermine digital providers is to offer the best of both worlds, and enable locally-based practices to offer reliable and safe digital ways to access our services.

Of course, this has to be done without leading to an avalanche of unrealistic expectations and demand, or in ways that undermines patients’ confidence to manage their own care, so it means practices being in control and using new systems for the benefit of everyone – patients, practices and the wider system as a whole.

Governments must join us in managing demand. It’s not just about directing more patients to pharmacy; it’s about empowering more people to self-care. It’s not just saying patients can be seen quicker by already overstretched GPs; it’s about reducing the over-medicalisation of society.

And if they really wanted to free up appointments they could stop anyone and everyone telling people to “just get a note from your doctor”. And to make a real difference to our workload governments could set an example by trusting people more and scrap the current antiquated, costly and completely unnecessary system of fit notes.

Governments must join us in managing demand...it’s about empowering more people to self-care

It really is time employers and government stopped passing the buck to GPs and that we all empowered our patients and stopped treating them like children.

We’ve made a start on that with our QOF changes in England this year, focusing on the personalisation of care and giving patients clearer opportunities to say not only what they want but also what treatment they don’t want.

Tackling overmedicalisation is crucially important as it reduces risks to our patients.But this year in England we’ve also delivered contract changes that reduce risks for GPs.s

We’ve delivered a comprehensive five-year deal that gives stability to practices, delivers year-on-year pay increases, expands our workforce and reduces our workload. We’re even teaming up with NHS England to lobby government on the urgent need to make changes to the pension system to help deal with the serious damage caused to recruitment and retention by the annual allowance. And while we were at it we’ve secured £20m to help cover the cost of subject access requests.

This year in England we’ve delivered contract changes that reduce risks for GP

But above all, we have removed the risk of indemnity. In England and Wales, for every NHS GP, partner, salaried GP and locum, working in hours or out of hours, once and for all, we have taken away the burden of unsustainable indemnity payments.

We’ve listened, we’ve acted and we have delivered.

This only happens by working as a team. I want to thank the team that works with me in GPC England, Mark Sandford-Wood, Farah Jameel and Krishna Kasaraneni, our policy team led by Dan Hodgson and our committee team most recently led by Nikki McIntosh and now Richard Pursand, as well as the many others throughout the BMA who support us. I also need to thank the policy leads, including our sessional subcommittee and trainees subcommittee chairs who so ably guide us with their advice.

And I’m privileged to work in an UK team as well, learning from and being supported by Andrew Buist, Alan Stout and Charlotte Jones. This will be Charlotte’s final LMC conference as chair of GPC Wales and we all owe her a huge debt of gratitude for the energy, enthusiasm, skill and commitment she has brought to this role. She leaves a legacy not just in Wales but across the whole of UK general practice. Charlotte, thank you.

Travelling the country following our contract agreement in England I’ve had a real sense that growing numbers of GPs believe that we are finally turning a corner.

There is light ahead of us. The 12 years of austerity we have had to cope with may be behind us, but the damage was severe and it will take many years to recover. But at last there is a sense of hope, a hope that we can rebuild general practice, that we can develop community-based services and that we can once more make being a GP an attractive profession to both join and stay in.

We are not there yet. We are far from complacent. There is much that needs and must be done. But, as GPCs and LMCs together, we will listen, we will act and we will deliver.

Readers' comments (3)

  • I'm looking forward to the speech in two or three years time to find out who he will blame when it all unravels.

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  • David Banner

    “The light at the end of the tunnel.......
    ....... is the light of an oncoming train”

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  • The light ahead is that one not to go towards when you have a near death experience, apart from in the death of GP land there will be no going back from this light BMA/GPC.

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