'Labour will put general practice at heart of NHS vision'
In full: Labour shadow health secretary Jonathan Ashworth's keynote address to the Pulse Live conference
It is a genuine pleasure to be here because Pulse is not only the persuasive voice of GPs, read by and influencing the very highest policy makers but equally Pulse stands in the fine tradition of campaigning journalism. From your campaigns in recent years against practice closures to most recently your dogged research highlighting the ‘cash for cuts’ referral incentives scheme.
This afternoon I want to offer a few reflections about the state of the NHS as we approach its 70th anniversary in July and offer some remarks on Labour’s thinking about how to ensure the National Health Service is sustainable in the future.
And the reason I so readily accepted the invitation to address you this afternoon is because I want this to be the beginning of an ongoing dialogue about the how we safeguard the future of the NHS.
I start with an absolute commitment to the value of list based general practice and ensuring universal access to primary care. The principle that everyone should have access to primary care when ill, free of charge, has endured since the creation of the health service 70 years ago and it’s a principle to which Labour steadfastly holds.
We know that general practice is not just highly valued by the public, accounting for 90 per cent of interactions with the NHS, but crucially as academic research has shown general practice is essential to a secure, effective and efficient health service too.
And the reason why, as we approach the 70th anniversary of the NHS and look to its next stage, we are so committed to strong general practice is because the health challenges we face over the next 20 years – from the ageing population with greater frailty in society, to the increasing prevalence of chronic conditions to widening health inequalities and the need to raise the health and wellbeing of the next generation – I believe all these challenges depend on high quality general practice and primary care.
So I want to put general practice at the heart of Labour’s vision for the NHS – the first building block in a health system which doesn’t just treat you when you’re sick but keeps you well in the first place.
But when I speak to GPs as I do often I hear very similar messages about the increasing, indeed some would go so far as to say intolerable pressures on them. The British Medical Association says that GPs are “exhausted”.
An ageing society places ever greater pressures on primary care as it does on secondary care and of course these demands will only increase as, for example, the number of over 85s doubles over the next 20 years. We are witnessing a relative shift away from acute illness, towards chronic conditions, multi-morbidities, cognitive impairments and long-term frailty. Over 50 per cent of older people have at least two chronic conditions and by 2035, the proportion of those with 4 or more diseases is set to double.
This is against a galling backdrop of falling GP numbers and wider vacancies, so far from being on track to deliver the 5,000 extra GPs the Government promised we have actually seen a fall of 720; meanwhile Pulse’s most recent annual survey of vacancies showed 12.2 per cent of all positions are currently vacant – an increase from the 11.7 per cent reported at the same time last year, and from a rate of 2.1 per cent when Pulse began collecting data in 2011. And far from investing in the wider primary care workforce there has been a fall of 343 General Practice Nurses too.
In deprived areas there tends to be the fewest GPs and nurses per 100,000 people. Yet talking to GPs who work in these areas they tell me there are greater pressures on their workload as changes to benefit systems, wider poverty and associated conditions like malnutrition have meant more patients presenting and we have more GPs now making referrals to foodbanks too.
There has been insufficient investment in training these last eight years at a time when we are in an increasingly competitive international environment as more middle income countries invest in their own health care systems. Canada, New Zealand and Australia have all become increasingly attractive locations not just for UK GPs but also for many of the international doctors who otherwise would have come to the UK to practice too. Of course Brexit has made the prospects for EU recruitment even more difficult. Meanwhile around 3,000 GPs retired before the age of 60 over these past five years and close to half of GPs are aged over 55 in parts of England.
Yet despite the pressures GPs tell me they consider their job an honour and a privilege and I’m not surprised that a survey this week revealed seven out of 10 GP partners say their practice delivers at least one non-core service not part of the core contract for no extra money from spirometry to ECG recordings, to post-operative suture removal to name a few.
So extraordinary, care and dedication despite the intense pressures.
But I’m also struck when I talk to GPs by how many worry and indeed fear their workload is unsafe.
One GP I spoke to, with over 20 years’ experience, told me she was often close to tears from exhaustion after a thirteen hour day, worried about the quality of the judgements she was making, “we don’t have the time to practice safely” she told me adding she “has to make decisions so quickly and under pressure.”
Or the young GP I spoke to, who said that her and her colleagues were attracted to general practice because they loved the values of general practice; loved looking after patients holistically over the long term. They want to get involved in local communities and build stable teams. They don't particularly want to do short term shift work. But they are finding it harder to manage the time pressures and feel that they often are working in an unsafe way so they look for other opportunities
This means we have young GPs who don’t feel they have the time to do the job to the standards they expect of themselves, who drop clinical time and indeed leave general practice all together. The remaining GPs have to work longer risking burn out. No wonder so many partners I speak to tell of their struggle to recruit younger GPs into long term roles
Therefore it seems to me that for too long we have taken that dedication for granted, allowed low morale and mistrust to fester.
Sadly I believe this low morale and mistrust has been exacerbated by the Bawa Garba case and the worry it has instilled in tired, overworked doctors who everyday are faced with managing risk, everyday have to make a judgment on whether or not to refer a patient.
As one GP partner told me recently the handling of this tragic case will lead to a sea change in practices limiting daily activity. The implications are obvious: greater pressures on access again risking even greater pressures on already stretched hospital A&Es and urgent care centres as well.
So what is Labour’s response?
We start from a belief that general practice is integral to helping us meet the challenges we face.
My Party has big ambitions to improve the quality of life and health of the population.
We want to see greater integration between health and social care;
We want to see health inequalities narrowing as we tackle the wider social determinants of ill health;
We want to reverse the years of neglect of mental health provision;
We want to tackle addiction in society
And for us every child matters so improving the health and wellbeing of our children will be a driving mission.
These are all important big ambitions that we can’t even begin to tackle without the major involvement of GPs and a properly resourced modern primary care service.
To that end we support the partnership model where it works and can recruit but equally we are aware that large parts of the country are indeed struggling to recruit GPs.
We don’t believe in a one size fits all solution so instead I want to work with GPs to develop models for the future including salaried GP models and indeed explore options with you for the future of the contract and the future of the Quality and Outcomes Framework which I think many agree hasn’t delivered as hoped for. And I want to begin a discussion with you about how we find more time for you to care and less time on managing bureaucracy. So I genuinely hope today can be the start of ongoing dialogue about what is possible, and reasonable for an incoming Labour government to expect of the GP workforce.
To be candid with you I don’t want to be a Secretary of State who issues unrealistic directives telling you to be open all day long 7 days week when the capacity simply isn’t there to deliver it, but in return I want to work with you to help improve quality across the board as that’s what patients expect.
And I want to work with you as we explore how we better integrate health and social care at a local level. Of course my Party will not support models that allow for greater privatisation in our NHS and we believe it’s increasingly clear that ever greater private sector involvement in the NHS is neither in the interests of the taxpayer, patients or NHS staff. Just take the example of Capita’s shambolic mishandling of the general practice patient records contract. The cost of fixing this for NHS England was £6.6 million.
So the next Labour Government is committed to eliminating privatisation with as little structural disruption as possible. Over the coming months we want to commence a discussion with GPs, primary care professionals and others across the NHS about the best way we can abolish the purchaser-provider split, get rid of wasteful and unnecessary competition in the NHS and replace it with truly local partnerships to deliver the fairest, most equitable and best quality care for local patients, their families and carers.
On workforce I can confirm that we as a Party will honour the commitment in the General Practice Forward View to recruit 5,000 extra GPs alongside commitments on the wider primary care workforce too.
Part of the challenge is making sure enough new recruits are coming through, and encouraging medical students to choose general practice. I was struck by the Royal College of GP’s Destination GP report that found that negative perceptions of general practice discourage some from joining the profession at a time when we urgently need more GPs. The latest recruitment figures show that 3157 were recruited into GP training for 2017, below the target of 3250. Although this is an increase on past years, it’s not enough to reach the workforce goals we need to be hitting. So Labour will look at how we can make general practice more attractive to medical students.
Of course successful general practice is also about skill mix and a team working with and supporting the GPs. We believe more must be done to support General Practice Nurses. With large numbers of the workforce set to retire in the next few years – a recent survey by the Queens Nursing Institute suggested that up to a third of General Practice Nurses could retire by 2020 meaning mean a loss of 8,000 GPN’s. What’s more compared to acute or other community nurses there is a gap in terms and conditions between nurses working in general practice and those working in the wider NHS so I want to work with you in looking at how we support the wider practice team.
We believe community and surgery based pharmacists, practice nurses, health visitors, district nurses, specialist nurses for diabetes and asthma, physiotherapists, occupational therapists, dieticians, geriatricians all have a vital contribution to make to patient care. My colleague Julie Cooper, Labour’s Shadow Minister for Community Care, will be leading a consultation on how we can ensure that Primary Care is an integral part of an NHS Workforce strategy that not only ensures that the service is adequately staffed, but respects and values the professional expertise of all staff.
Finally let me say a word about health and social care funding.
We know the NHS is suffering from the biggest financial squeeze in its 70 years history. Social care provision has been devastated by £6 billion worth of cuts not only putting intense pressures on the acute sector but placing huge pressures on GPs as well. General practice has seen its funding squeezed now getting a smaller percentage of the overall health budget.
In the acute sector we’ve seen a winter crisis likely to stretch beyond Easter, hospital wards at capacity. We are in a vicious circle. The squeeze on primary care driving more to secondary care while cancelled elective operations and growing RTT lists in turn place more pressures on GPs supporting those waiting longer in pain and distress for procedures and operations.
So I agree we do need a long term investment plan for our NHS and care sector, urgently, patients simply should not be expected to wait any longer.
But when we see waiting lists at around 4million, when we see ambulances backed up outside overcrowded hospitals, when we see operations cancelled not just electives but cancer operations too, when we see elderly confused vulnerable patients stranded on trollies in the corridors of bursting wards then I’m afraid a nod and wink from the Prime Minister isn’t good enough.
My Party is prepared to take the tough decisions for the long term sustainability of the NHS, we would make different choices on levels of taxation and this year boost NHS spending by an extra £5 billion.
Because the future sustainability of the NHS depends on the future of the social care system too we would allocate an extra £1 billion to stabilise the social care sector this year as part of an extra £8 billion across a Parliament.
Our shadow social care minister Barbara Keeley is developing plans for a national care service and has confirmed the next Labour government will implement a maximum limit on care costs at a more generous level than currently set in the Care Act regulations and we will also raise the asset threshold to a more generous level than it is under the current system too.
You know as well as we do that in the future of the NHS depends on quality health service provision in the wider community.
So we will ring fence and expand public health budgets including creating a new £500 million child health fund to invest in our ambitions to improve the health and well-being of every child. We will also ring fence and expand mental health services budgets to genuinely deliver the parity of esteem patients deserve.
My party has long campaigned for a fair deal for NHS staff but we want to go further than the Government’s offer. We will bring back the training bursary to recruit the nurses, midwifes and allied health professionals of the future and to support the existing workforce rather than cutting Continuing Professional Development we will invest in it.
And we will establish a £10 billion capital investment fund to invest in our NHS infrastructure, buildings, beds, latest equipment and technology.
These are the levels of investment that patients who have had a cancer operation cancelled or the elderly patient waiting hours in a hospital corridor needs now.
So the test of Theresa May is whether she genuinely delivers the significant long term investment package Labour is offering or whether it will turn out yet again to be more thin Tory gruel.
Given how central primary care is to our future vision of the NHS, absolutely key to our ambitions to tackling ill health and wider heath inequalities in society, general practice will get its fair share of this investment too.
A Labour government will honour the spending commitments made in the General Practice Five Year Forward View and we will ensure the amount spent on general practice and primary care rises as a proportion of the overall NHS budget.
Primary Care has suffered from a decade of underinvestment in infrastructure. We know quality primary care depends on high quality modern safe facilities not crumbling buildings that have not been upgraded for years or ancient IT systems running on slow networks unable to cope with the demands that modern health care systems need when sharing data. We also know there is more that can be done to embrace modern technology to offer convenient and different types of access to those who want it.
So as part of our overall infrastructure plans we will establish a national programme of primary care modernisation starting with a £500 million primary care capital fund to support the upgrade of facilities and investment in new technology.
In closing there is much to admire about primary care in the UK and some of the services around the country rank among the best in the world.
I want us to work together to ensure general practice and primary care to flourish for the long term.
My promise to you: better funded general practice, better support for the primary care workforce and a long term plan to give you the time to care for your patients and do the best possible job as the bedrock of our NHS.