'It's not safe for patients to carry on the way we are'
Read the full text of GPC chair Dr Chaand Nagpaul’s passionate speech to the Special LMCs Conference
The mere fact that an extraordinary conference has been convened, bringing GP representatives from all corners of the UK to London on a Saturday, speaks volumes about the state and crisis facing general practice today. We should of course not need to meet at all, since today’s reality was both entirely predictable and preventable.
Using Simon Stevens own words last summer ’we’ve systematically underinvested in general practice for at least 10 years’. This progressive resource starvation and thoughtless workforce planning has resulted in the proportion of NHS doctors who are GPs reducing from 36% to 25% in two decades and with fewer GPs per head today than 2010.
Yet we’re now seeing a record 370m patients annually in general practice- that’s 150,000 more patients daily compared to 7 years ago. This gross mismatch between demand and capacity is untenable, with both GPs and patients suffering the dire consequences.
This conference demands an end to the pretence that all is well on the road to recovery. It’s not.
Patients are being short-changed on a daily basis, with nine in 10 GPs stating that workload pressures are damaging quality care to patients.
This is a disgrace in a system in which the government promotes quality and safety as central to the NHS.
It’s not safe nor sustainable for GPs to see patients with complex multiple morbidity in 10 minutes, many of whom will be on over 10 different medications, and with heightened risk of medical error.
It’s not safe for GPs to have up to 70 patient contacts daily conveyor belt style, and on top of that plough through 100s of clinic letters, pathology results and reams of repeat prescriptions.
It’s not safe to discharge patients out of hospital and expect GPs to manage complications beyond their competence. It’s not safe for investigations to be requested by other doctors, and ask GPs to chase them up and blindly interpret them.
It’s not safe for GPs to be told to prescribe specialist drugs outside their expertise and worse without even seeing the patient.
It’s not safe for GPs to be examining patients while simultaneously having to take urgent calls from hospitals, district nurses and social workers, and also be called for an emergency home visit at the same time. It is not safe for practices struggling with unfilled vacancies to be forced to carry on registering patients when they haven’t the doctors or nurses.
And it’s not safe to fuel the political hyperbole of routine seven days services, taking GP away from ill elderly housebound patients in greater need.
To put it simply, it is not safe to carry on the way we are, and which is why this conference is highlighting that general practice is quite literally in a state of emergency
And we must put an end to the adulteration of the word “safety” by an inspection regime in England that measures safety in terms of curtain cleaning schedules, scrutinising minutes of meetings and expecting an encyclopaedia of polices as an end in itself.
And this is why GPC has totally rejected CQC’s proposals to hike its inspection fees seven fold, since we’re challenging root and branch a process that is disproportionate, nit-picking, crude and flawed.
There are more motions on CQC than any other part of the agenda today highlighting the damaging impact this regime is having, and why over 1900 practices responded to GPC’s current CQC survey in less than 2 weeks.
Nine out of 10 GPs believe that CQC’s ratings are flawed or misleading, and less than 3 in 10 practices rated ’good’ felt their inspection was an accurate measure of quality, and so it is not about an axe to grind. Nearly 8 in 10 practices say they reduced care for patients while spending days per month in preparatory paperwork, and thousands of appointments nationally are cancelled on the days of inspections, denying patients access to GPs and nurses.
Of course we need to regulate for safety, and we’re not talking about turning a blind eye to poor care.
But what we don’t need is a bloated behemoth charging £40m to identify 4% of practices deemed inadequate, while the true cost to the NHS is far higher with practices spending millions more on GP locums, overtime and backfill in preparing for and enduring inspections. This could instead pay for up to 1000 more GPs to provide frontline care for patients
Further it’s tragic that GPs and practices live in a climate of fear, in which CQC takes no account of your circumstances, and blames, names and shames you even if you’re running on empty with skeleton staff, or locked into inadequate premises not of your own choosing.
Eight out of 10 practices said preparing for CQC inspections was ’very stressful’ at a time of already rock bottom morale, and 80 % of GPs stated they’re more likely to want to leave the profession as a result
Our survey also showed CQC refusing to reschedule inspections even in extenuating circumstances when the lead partner or practice manager was off sick, adding further stress and tarring practices with a public label based on visiting them on the wrong day.
Yet CQC has the double standard of unilaterally cancelling inspections at a moment’s notice. We received several hundreds of heart-breaking comments from practices in our survey, but I’ll give just one example: ’We are fearful. I feel bitter because the workload and pressure in preparing was that high that decisions were made such as not visiting some terminally ill patients. The extra mile of caring we do was devoid in the weeks to the lead up to the CQC visit.’
What’s tragic is that 1 in 4 practices state they are less likely to raise concerns about practice pressures because of fear of CQC reprisals, and it’s a travesty that a regime designed to regulate for safety is itself perversely undermining safety.
The government clearly appears not to have read a single word of Don Berwick’s post Francis safety report commissioned by the Prime Minster himself in which Berwick calls for an end to a blame culture in the NHS and highlights that safety is in the hands of systems not individuals - I quote: ’NHS staff are not to blame – in the vast majority of cases it’s systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.’
Conference it’s therefore outrageous and unacceptable that we have a law compelling practices to pay for a regulatory system they believe to be flawed, one that does not measure quality fairly and in fact undermines it, and worse a system that’s compromising safety with collateral damage to the majority of hard working practices.
So no Conference, we have absolutely not failed as a profession, rather a costly unfit for purpose regulatory regime has failed English general practice and patients alike.
And it’s this very regulator that is inadequate and needs to be put into special measures, so that GP surgeries can be given the support, resources and time to improve quality, assure safety and be there caring for our patients.
I’ve already put to government a simpler, cost effective and proportionate alternative based on targeted support to ensure safety, with quality improvement being a facilitative peer review process.
Let’s now talk about being ashamed. You know what I’m ashamed of? I’m ashamed of successive governments that have callously disregarded the needs of patients by defunding general practice from 11% to less than 8% of the NHS budget, to the extent that GPs are forced to process patients akin to an assembly line, in which GPs aren’t even afforded the health and safety limits provided to other workers.
I’m ashamed there’s been a rocketing of GP practice closures in the last year, displacing over 200,000 patients forced to re-register. I’m bitterly ashamed that the Commonwealth Fund recently reported that the UK - the birthplace of holistic general practice - now has the most stressed GPs who spend the least time with patients out of 11 western nations studied
I’m ashamed that the government considers it a crisis if an arbitrary 94% rather than 95% of patients are seen in less than four hours in A&E, while totally ignoring the far greater crisis that 1 million patients daily are denied the quality of care GPs would like to provide.
I’m ashamed that politicians recognise the term ’deficit’ in all sectors of the NHS except in general practice where the word ’bailout’ doesn’t exist either. And while I’m immensely proud to be a GP, I’m ashamed that I’m working in a system that prevents me from doing my job properly caring for patients.
Conference, while we must keep shouting from the rooftops about the crisis affecting general practice, ultimately we have come together today to discuss solutions - about how to resuscitate general practice, how to ease the pain and exhaustion amongst a demoralised workforce, and how to build a sustainable future for a job that means so much to me, to you and of course to our patients.
The first priority must be to stabilise the current brittle landscape and support practices at risk of imploding from harsh funding cuts, or practices at a tipping point unable to recruit. I’ve said before that only a 6% reduction in general practice capacity would double the number of patients attending A&E if they went there instead.
The government therefore cannot afford for a single practice to close unnecessarily since this costs hugely more in hospital costs and the expense of picking up the pieces. It isn’t a case of the government not having money, but about responsibly saving money by saving practices.
And it’s a scandal that area teams say they don’t have tens of thousands of pounds to stop a practice closing, but can in the same breath spend over a million pounds on challenge fund schemes to pay GPs to sit in empty surgeries on Sundays. This is plainly morally wrong.
So in England the government has made £10 million available to support ’struggling practices’.
This totally misses the point that all GP practices are struggling, even those branded outstanding in CQC inspections tell us they are fighting for survival and are equally vulnerable to closing. And the idea of providing a crumb of resources on a one-off basis to a few won’t solve the problem.
Conference, general practice does not need a disaster relief fund - it needs proper recurrent and sustained resources for all practices to have the infrastructure and capacity to meet relentless escalating demands.
We also require proactive support. We’re all vulnerable - even the most apparently secure practice today could be a victim tomorrow, with one partner retiring early, another falling sick, a nurse going on maternity leave and if there aren’t the applicants to fill vacancies it will suddenly find itself on a cliff edge.
We hear of such examples daily. Sadly countless practices have needlessly folded and destabilised patient services, and which clearly could have been avoided by pre-emptive plans.
We need a system in which practices worried about their ability to cope can hold their hands up in advance in a nonthreatening climate, with resources to support them to get back on their feet, and protect patient services - not wait for them to keel over to be labelled a struggling practice.
GPC has already put specific proposals to NHS England to resource local resilience teams, with GPs, nurses and managers able to be parachuted to any practice at short notice. GP federations for example could be funded to do so, and it is incumbent on government to safeguard patient care by implementing this forthwith.
We also need immediate workload limits. Inappropriate, unfunded, and excessive workload has to stop in the name of patient safety, and our BMA survey showed this is the greatest reason driving GPs out of the profession.
We cannot continue to allow GPs to work inhuman hours in a day with a punishing intolerable intensity.
GPC produced our Quality First workload management document a year ago- and it’s crucial to restate that our contractual professional duty to patients is to provide them with essential services.
No patient should suffer from a GP not being there for them because the GP is diverted doing work outside their contract.
No indemnity organisation or the GMC will come to our rescue and consider exhaustion or overwork as mitigating factors if safety is compromised. We therefore need a shift in mind-set where we must cut our cloth according to the resources we’re given to safeguard our own and our patients’ health, and openly challenge and whistleblow any national and local system that undermines this.
Put another way we must learn to say ’no’ to that which takes us away from doing our core job, in order to say ‘yes’ to providing safe quality care for our patients.
NHS England’s own commissioned research ’Making time for general practice’ published in September staggeringly revealed that 27% of GP appointments were avoidable. Hardly surprising when the suffix to any unfinished work is ’see your GP’. We cannot continue playing pass the workload parcel where the music always stops at the door of general practice.
As a result GPC is working with NHS England to run a series of roadshows with LMC involvement starting next month specifically with the aim of reducing inappropriate workload, bureaucracy and releasing capacity.
The government has accepted our call for an end to automatic GP re-referral of patients missing hospital appointments, and GPC will be seeking an end to GPs chasing up hospital test results and follow up appointments, as well as enabling appropriate internal secondary care referrals with patients having direct access to hospitals for problems post discharge.
This needs coordinated work on the ground by LMCs, practices, hospitals and commissioners to collectively put in place local systems of workload management.
And a non-negotiable principle is that resources must follow where care is delivered. More out of hospital care means more out of hospital resources period
But we must also manage demand. Given the government a year ago launched its ’say no to A&E’ campaign to use emergency services appropriately, it’s shameful that in the same breath we’ve seen the stoking up of demand on GPs in the face of dwindling resources.
GPC calls upon government to similarly put out an unequivocal public facing message that general practice too is crippling under strain, that it needs to be used wisely, and to signpost patients to use other services where appropriate.
The government must also back a national self-care campaign to empower patients to manage their own health for both minor and chronic conditions, avoiding having to unnecessarily sit in GP waiting rooms full of ill people
Turning to workforce, the pronouncements of 5000 extra GPs by 2020 is an irrelevance given the government’s total oblivion to the elephant in the room - which is retention.
The government’s own commissioned GP worklife survey from the University of Manchester published just three months ago shows 38% of GPs intend to quit in the next five years, even higher than our own BMA statistics; That represents a loss of over 10,000 GPs that will wipe out any increase in recruitment.
This is compounded by increasing numbers working part time due to workload pressures, resulting in net reductions in GP capacity below crude headcounts.
So what can be done? Well you aren’t going to improve retention nor recruitment by just talking up the job with promotional videos, flying in the face of the reality of an overstretched exhausted workforce. The job has to sell itself in actuality, and that means putting in place a manageable and rewarding workload, so that medical students and foundation doctors when they experience general practice want to be GPs and existing GPs want to remain in a job they enjoy.
Therefore while we’re thousands of GPs short today, and given we simply can’t magic up GPs tomorrow, we need immediate skill mix support from other healthcare professionals who can see some of our patients, do much of our clinical administration and ease our workload burden. And that needs resources- not pilots of short-term funding to a few, but sustainable resources and follow the lead in Northern Ireland where every practice will be supported by a fully funded pharmacist.
And we need primary care teams working across the walls of GP surgeries, with integrated community nurses and health professionals visiting and caring for vulnerable housebound patients putting an end to the GP always being the first port of call regardless of whether they are the best person to deal with the problem.
Conference, we are here today as representative leaders and we also need a fighting spirit to do what we can ourselves to protect our discipline, and to restate our status as GPs and independent contractors in which we do have some control over the way we work and organise ourselves.
That’s why a key proposal from GPC’s vision document is to create networks of GPs and practices supporting each other to facilitate collaboration, share resources, staff and provide cross cover with the strong protecting the weak.
A spirit of collectivism where we see ourselves as one GP profession, working with and for each other in local communities with common identity and synergy between sessional GPs and partners, rather than working in parallel to each other.
And that’s where LMCs come in as brokers, leaders and change agents to create this community of collaborative GP resilience. Networks that cater for the increasingly diverse career aspirations of GPs, including those who wish employed status and portfolio working but with career progression and inclusivity rather than the current sessional arrangements in which many feel disenfranchised.
And this is why we have told NHS England to give us the organisational funds to create such networks. And for the avoidance of any doubt this is not about diminishing individual practice units, but strengthening and protecting practices both small and big, so that they are sustainable. Because the practice unit is the kernel of personalised continuity of care that defines the absolute success of UK general practice.
I want to talk now about our patients. They are our allies and we exist because of them, and I’d like to thank them for seeing through the media smears and mud that’s slung at us, and for continuing to have faith in us with recent figures showing 92% of patients trust their GP, higher than any other profession, contrasting with 16% who trust politicians. And an extraordinary 85% of patients are satisfied with their GP service in the recent National GP survey in spite of the fact we are working against all impossible odds.
We must never take this support for granted, and why whatever measures need to be taken to deliver a safe and sustainable service, they must be taken with our patients understanding our plight, with them on side, and in partnership with them.
Our patients must be told that the reason they’re waiting longer to see a GP, the reason we don’t have enough time for them is not of our making, but a direct result of government neglect where we’re at least 10,000 GPs short to meet demand. And we will argue the case for general practice from the moral high ground that our earnest aim is to be given the tools and space to do our jobs and what’s best for patients, and unlike politicians it has nothing to do with the vested interest of electoral timeframes or winning votes.
I want to scotch the oft quoted myth that all we do is complain without solutions, since I’ve today described a wealth of ways in which general practice can be turned around from a vicious cycle of negativity into a virtuous cycle of positivity. GPC produced a comprehensive solutions document last year, and we will spell out more in launching our imminent campaign an Urgent Prescription for General practice.
Conference, we’ve heard lots of platitudes from the centre over the past year. We heard about the New Deal that never was. The Five-Year Forward view is explicit about the need to rebalance funding in favour of primary care. And most recently Jeremy Hunt stated he will announce a support package for general practice in February.
We are sick of hearing just words, but now need to throw them back to government to demand real delivery. We don’t want to hear about last year’s money rebadged as a new resource. We don’t want to be to be told about what may or not happen in 2020. What we need to know is what the government is going to now do to enable 1 million patients daily to receive a safe and sustainable GP service today
I’m constantly told by ministers that the greatest battle is getting money out of treasury.
My message to the chancellor is to use his financial nouse- stop penny-pinching and be pound wise, grab yourself a bargain while there are GPs out there because once they’re gone they’re gone – since it costs £136 for all-in unlimited care and home visits per patient per year which is less than the price of walking through a single outpatient clinic door once
So, Conference, today marks the great fightback of UK general practice. I urge government to do the right thing for patients and equally the right thing for a GP workforce whose goodwill continues to be shamefully exploited. And to protect and nurture a discipline that’s not just the jewel in the NHS’s crown but a beacon of personalised continuity of care internationally. And to make 2016 the year in which we begin the revival of UK general practice so that we have a future generation of GPs to look after a future generation of patients