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In full: Jeremy Hunt on GPs taking back out-of-hours care

The speech given by health secretary Jeremy Hunt on GPs taking back responsibility for out of hours care at the King’s Fund.

Today our NHS faces unprecedented challenges. And some big choices if we are to offer the kind of care we must to an ageing population.

Making the right decisions will demand courage, determination and most of all leadership - nationally, but far more importantly, from doctors and nurses locally.

Inevitably, post-Francis, the focus has been on hospital care. But today I will argue that improving primary and community care is equally important – and perhaps the more urgent priority, because it is from this that so much else follows.

In particular, I will make the case that we have allowed ourselves to lose sight of the concept of the family doctor - the sense that GPs are there to be a champion for their patients rather than simply a gateway to “the system”.

But mine is an optimistic argument. I believe that every patient is the only patient. And I will say that strengthening personal relationships in modern care holds the key to many of the challenges we face if we are to look after our growing elderly population with dignity and respect.


We should be clear about the scale of the challenge.

One in four of the population has a long-term condition - many of them older people. Within the next few years, 3 million people will have not one, not two, but three long-term conditions. By 2020, the number of people with dementia alone will exceed one million.

We cannot treat chronic conditions on this scale with the systems, responsibilities and incentives we currently have in place. Too often care is reactive and disjointed, with mistakes caused as a result and in a way that endangers patient safety. Too rarely are our vulnerable older citizens looked after with a joined up care plan that pre-empts problems before they arise.

Now for the avoidance of doubt let me clear who I do not blame for this - and that is the professionals in the NHS, whether doctors, nurses, GPs or community practitioners.

Last year on a broadly flat budget, the NHS did 400,000 more operations than in 2010. There were a million more admissions to A & E. GPs now provide in excess of 300 million consultations every year.

All NHS staff are working extremely hard in the face of rising demand for their services, and they are working possibly harder than they have ever worked before. In fact, they are the ones who tell me how much better things could be organised - and it is conversations with them on the frontline that have informed my thoughts today.


Everyone agrees that hospitals should only be a last resort for the frail elderly and that - for someone perhaps with dementia and other complex conditions - A & E departments can be extremely confusing places. But what alternatives do we offer?

- Too often GP surgeries where it is impossible to get an appointment the next day;

- Same day appointments but only if you call at 8 o’clock in the morning sharp and are lucky getting through;

- Too often long waits on the phone to get through, sometimes at premium rate numbers which were supposed to be banned in 2009;

- Difficulty in registering with another practice if you move home, or aren’t happy with the service you are receiving;

- Out of hours services where you speak to a doctor who doesn’t know you from Adam and has no access to your medical record;

- District nursing services are excellent, but can be very hard to access; and

- Urgent care centres whose role is little understood by the public.

Hardly surprising then, that people turn to hospitals and that across England our 150 A & E departments are the busiest in their history.

Something we all know is simply not sustainable.


And if it doesn’t work for the public, it doesn’t work for GPs either.

They feel rushed off their feet with a daily list of duties that can make it extremely challenging to develop trust with patients and exercise responsibility for their care - the very reasons that motivated them to join General Practice in the first place.

Things were by no means perfect before 2004. But it is clear now that in that year some changes were made to the GP contract which fatally undermined the personal link between GPs and their patients.

The new contract said that GPs were no longer responsible for their patients all the time, but only during working hours Monday to Friday. So at a stroke the need to think holistically about a patient’s entire needs was removed - although to their enormous credit many practices still make superhuman efforts to do this even under the new structures.

The result of that historic mistake is that GP practices are now remunerated not for looking after people as individuals, but for complying with a myriad of targets and requirements: the Quality and Outcomes Framework; Quality and Productivity; Direct Enhanced Services; Local Enhanced Services; Local Incentive Schemes and others too.

All of these targets are designed for important reasons: boosting immunisation, managing blood pressure, early diagnosis, HIV testing, extending hours and so on.

But taken together, the result is we reward GPs not for putting patients first, but for the number of biomedical boxes they tick when someone walks through their surgery door. “It’s like the patients have their agenda and we’ve got ours” as one GP told me.

And with every target or process comes bureaucracy and paperwork. Updating different computer databases, chasing up test results or diagnoses or scanning in letters from hospitals. One GP practice I visited recently actually had a post called “head scanner” because of the volume of letters they receive, that have to be scanned in and linked to a patient’s medical record, a function that takes around 6 hours every day.

The consequence? We have turned GP practices into largely reactive places - sometimes with the feel of a mini A & E department - where the daily challenge is not keeping a watchful eye on the health of people on their list but simply keeping a head above water in the face of queues outside the surgery door, large call volumes, long appointment lists and mountains of paperwork.

And the proactive work of a family doctor - checking up on a frail older patient recently discharged from hospital, phoning someone who is depressed and living on their own to see how they are, looking up when someone suffering from recurrent back pain last came to see them - is too often  forgotten or left undone.


Out of hours services are perhaps the prime example of where things have gone wrong.

We have had teething problems with the new 111 service.  They were not acceptable and we are sorting this out. But those problems have rightly focused public attention on the variable quality of out of hours GP services.

No one is suggesting that GPs should go back to being personally on call during the evenings or weekends - they work hard, they have families and they need a life too. But should the quality of out of hours care for people on their list really have nothing to do with a GP? And is it right that most out of hours providers can’t even access your medical record even with permission?


Which is all part of the same problem.

Patients in hospitals are under the care of accountable clinicians. The consultant responsible doesn’t do everything him or herself. But if something goes wrong, you know where the buck stops.

But when a vulnerable older patient needing follow-up and ongoing support leaves hospital, who is the accountable clinician?

As a member of the public, I would like that to be my GP.

I’m not talking about one person personally providing every element of care for a vulnerable parent or grandparent. Clearly, there will often be important roles for geriatricians, district nurses, social workers and others.

And we can debate whether in certain cases the accountable clinician might not be a GP - just as in hospital sometimes the individual responsible consultant can change based on the needs of a patient.

But at any stage, a patient, or his or her family, should know where the buck stops.

That there is someone whose job it is to know how someone is, ensure good care is in place, and make sure there is access to good advice both in and out of hours. Someone who helps our most vulnerable older people navigate their way through the complex and sometimes scary world of health and social care.


Reclaiming the ideal of family doctoring in the 21st century means making sure clinicians are accountable for people who are unwell - whether inside or outside hospital.

It means responsibility for more proactive care. Just as intentional rounding has transformed nursing care in hospitals by heading off problems before they arise, so proactive case management can help keep people healthy and happy at home rather than having to be rushed to hospital in an emergency.

But it does not mean mandating a single model for primary care from the centre and seeking to “roll it out” irrespective of local circumstances. The NHS has tried that many times before with very mixed results.

In fact we need quite the opposite: bold experimentation with integrated care models where our focus is on outcomes rather than inputs and processes, something that Norman Lamb was talking about here just last week when he announced his integration pioneers programme.

Indeed if we do that I am convinced we have the keys to unlock global best practice right here in Britain, where from last month commissioning now lies in the hands of GPs. But we need to go much further, actively combining the best traditions of NHS primary care with the transformative power of modern technology - not just for the benefit of clinicians but also to help patients to manage their own conditions.

And just as we as ministers ask for this innovation from doctors, they can legitimately challenge us: on the need to remove the barriers that still exist to joining up care, something we are addressing in the Vulnerable Older People Plan; on the need to ensure that enough new doctors are joining General Practice; and on the need to ensure that Primary Care is able to get the resources necessary to prevent and head off serious illness in a way that has often been talked about but never delivered.


Finally, getting this right will need a complete overhaul of how GPs are assessed by the CQC. Too many GPs feel that the current registration system feels like yet another tick box exercise.

As with hospitals, we need to reform inspection so that it makes a holistic assessment of what General Practice is for. Inspections need to look at clinical outcomes, patient care, access and safety. But most of all - just like in hospitals - inspections need to look at whether the practices are putting the needs of patients at the heart of their work.

So I am pleased to announce that we will this year appoint a Chief Inspector of General Practice to help drive up standards of excellence in GP practices across the country through clear, open and robust assessments of how well each practice is serving its patients. Working inside the CQC, the new Chief Inspector will work alongside the Chief Inspector of Hospitals and the Chief Inspector of Social Care.

This will involve working together to make sure that primary care, hospitals and care homes are all playing their part to provide a seamless, joined up and integrated service for people with complex needs. The Chief Inspector of General Practice could have an additional responsibility to assess the degree to which this joining up is actually happening.


Many of the problems I have articulated today are what I have heard from GPs themselves - and we need to involve them in designing effective solutions. So let me finish by saying what a GP once said to me.

“The strength of general practice is the trust between me and my patients. I need my patients to be able to trust our relationship even when the surgery is closed. I have to be sure that there are plans in place to look after them, to avoid problems rather than just deal with them. This relationship which spans the highs and lows of life is why I became a GP.”

These ideas are not going against the grain of what GPs want. Nor are they trying to turn the clock back to an ideal that probably never really existed as much as we imagine.

But even as technology changes so much, some fundamentals must remain constant: the importance of people, of relationships, and of accountability.

If we are to succeed, we must rediscover the concept of personal responsibility for the care of our most vulnerable - something that most GPs have always felt should be at the heart of their profession.

Family doctoring in a 21st century environment with all the opportunities presented by a networked world.

But never losing sight of what the NHS has always stood for: a society where we can grow old with confidence and security that when it comes to ill health there will always be someone there for us when we need them.

Readers' comments (23)

  • Strangely I find myself agreeing with some of these statements. We have had 10 yrs of QOF and am unsure whether the outcomes match the mind numbing amount of time I have put in as my practice QOF lead and would jump off that hamster wheel tomorrow.
    The thing I really enjoy now is spending time with patients.
    However I do not want to return to the time when my family were disturbed at night by patients phoning to tell me that they cannot sleep after a 12 hr day and I don't think any of my junior partners would either.
    We cover 60 hrs of the week now but there are not enough of us to cover the other 108 hrs in the week in the same way without significantly affecting the weekday service. This deficit is heightened by the training GPs finding it difficult to work a full time week as it stands. I know we are very creative folk but don't think we can bridge this particular gap....

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  • What a complete fool! Let's stand united and vote no. If he wants to take our contracts then so be it. He can then spend lots of money recruiting us all back as there will be no GPs in the NHS at this rate. Patients need to realise they won't have an NHS if they abuse the system and place ridiculous demands on their already overworked, and quite frankly, underpaid GPs!

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  • If I hadn't made my mind up already, I have now. I'm retiring as soon as possible. I am sick to the back teeth of neuropaenic politicians using the NHS/GP's as political pawns to score points off each other. Someone give me a stiff drink.......I think I'm going to need it!

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  • Seems a sensible and realistic assessment of current UK general practice. Good, but could be so much better.

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  • i feel a bit out on a limb here but i have read the speech carefully and there is much in it that rings true. at least he gets that CQC in current form is wrong and the pressure to tick boxes and deal with the endless demand is undermining the best of what we do. many good sentiments Mr Hunt,so help us deliver this shift in emphasis so it isn't just rhetoric.

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  • My generation of full time largely male GP's is now at or approaching retirement. We put our patients ahead of our wives and children.We worked every week day and at least one or two nights a week and alternate weekends and Christmas days etc. We were chronically tired and our health and hobbies and families suffered. Despite all this we felt valued by our patents and largely content with our lot. The new generation of doctors now works mainly part time with a day or more off each week. They do not have do the treadmill of nights and weekends in addition to full days at work any more. They are increasingly female with family and holiday commitments and have a far better work life balance than we ever had. They are better paid now and quite simply will not tolerate a return to nights and weekends work again. The Politicians have broken the vocation that was General Practice with their constant meddling. It is now a job like many others and Mr Hunt will need to think again. The genie can not be put back in the bottle.

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  • QOF, CQC, ever restricted access to secondary care, services that come and go, District nursing teams depleted and moved out of GP surgeries, discharge summaries that are hopelessly brief, inaccurate or absent, government initiated walk-in-centres that patients are "allowed" to access and A&E departments that they are not. All of this and more is on our plate. We do our best, sometimes you feel like you are only fire-fighting.

    And yet despite it all, most of us still have time for the patients story. That is what is at the heart of General Practice and it is why the vast majority of patients are still satisfied with our service. I would like more time to listen to my patients and make the occasional pro-active phone call, but its never going to happen unless the politicians stop micromanaging us. I have no confidence that Mr Hunt will make that happen, for all his rose-tinted rhetoric.

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  • 'District nursing services are excellent'
    There is no doubt in my mind that over the last 15 years DNs have done less and less while our practice nurses have done more and more, and really are pretty irrelevant now..
    I could surprisingly agree with quite a lot of the rest, but I was one who opposed the new contract.
    But then just when I'm slightly amazed to be agreeing with Jeremy Hunt, it all falls apart when he mentions a new inspectorate!? Even more loaded on...

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  • GPs look what the government wants is a factory worker scenario for GP , probably wearing dungarees and clock in clock out , with eventually a Bruce Springsten song !.
    Truth is GP,will fold because most in power have no backbone . Our BMA GMC lMC RCGP all the letters have a certain type of character ---namely politicians and we all know the weight of their word. Hospital doctors sadly have no clue and will happily bash other doctors for a chocolate cookie if it means they get a bigger chair so as to speak
    I predict that we will be abused more , we will be treated like rubbish , we will have no choice , the world will go on about vocation vocation vocation and everyone loves passing responsibility
    We are a dying profession if not nearly dead and this is the future
    Anyone who disagrees or thinks I am dooming it all can come back in 2 years and see what I have said is true
    What are we and I have realized that we are just a another brick in the wall , --only difference is we are not on the dark side of the moon full view , with full responsibilty of all the other bricks no matter how they are decided by questionable builder

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  • Unreasonable patients generate indifferent primary care but the there is and never was any justification for breaching the continuity of patient care when we entered medical profession .
    That said politicians should not impose contractual changes without consent of those who have to work through these challenges.

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