RCGP chair: ‘GPs on the frontline just can’t afford the investment in technology’
RCGP chair Professor Helen Stokes-Lampard’s address to the College’s annual conference, in full
Good morning conference.
It’s so great to be here in wonderful Glasgow once more and what an uplifting start to proceedings. Thank you to members of Council who plotted to make that flash mob a reality!
I just want to start by mentioning Enid, my lovely patient who was the focus of my speech to you last year. As so many of you have asked, I want to reassure you that she is doing fine.
I am not going to spend the next 20 minutes discussing Enid, or any other patient of mine, but by sharing her story with you last year, it did lead onto to some amazing things happening.
The whole social isolation and loneliness agenda is now firmly in the public & political conscience. We launched our RCGP action plans on tackling loneliness in all four nations, and I have been working with Tracey Crouch, the UK Government Minister for Loneliness.
So, thank you for embracing and working with the concept of GPs wanting to deliver truly person-centred care: ‘Enid-shaped care’.
But today, I want to focus on technology - the contrast between tech-savvy and technophobe, in an era where we have a veritable tech tsunami raging around us.
And as 2018 is a year of anniversaries, including the 70th anniversary of the launch of our NHS, I also want to look ahead to the next 10 years and talk to you about our ongoing work around our future vision for general practice.
So, technology and GPs.
I’d like you to cast your minds back 20 years, just 20.
In 1998, my husband and I bought our first modern home computer. We immediately connected to the internet and had an email address, but actually, we were ahead of the game. At that time, only one of our friends had a personal email address; online banking didn’t exist; our mobile phone was the size and weight of a brick; Google and Microsoft Office were born that year; and a company called Amazon was selling books from a shed in America.
I suspect history will record the subsequent two decades as the ‘communications revolution’.
The way we work, learn and play has been transformed since then.
I am a patient woman, some say I am too patient at times, but I get really exasperated when I hear accusations that GPs are technophobic dinosaurs.
What utter nonsense. What total codswallop!
GPs are not afraid of technology or innovation. We are bright, intelligent people who gladly embrace good, safe technology.
We were the first part of the NHS to have computerised records, to have electronic prescribing, to collect coded data, to go paper light, and then paperless. And let’s be honest, most of us do love a new gadget, some wearable tech or a new time saving innovation.
I like to consider myself reasonably ‘tech-savvy’ and keep up with the latest ideas and innovations.
But, I faced a major tech challenge when my surgery merged this year.
We merged with the other practice we already shared a health centre with, similar patients, and staff that we know and like.
On paper it should have been the easiest form of merger, but it was hard.
It was a horrible experience.
Change is always hard, even wanted, ‘planned for’ change. But, do you know the single thing that made it the hardest? The IT.
I won’t name them, but our software provider refused to let us merge our web-based consulting system when we wanted to. Instead, we were firmly given just two options for ‘dates’ we could go live, one three-months later than we wanted, one four-months earlier.
Delay would have meant missing the chance to bid for new funding to help us merge and missing out on initiatives that were only available to groups of a certain size. So, we rushed to get ready for the early one. We were forced to cut short the planning, the training, the networking and building of relationships.
All for the convenience of an IT provider.
So, we merged as the winter pressures hit, as QOF pressures built. And that IT-induced haste meant a different member of my staff cried on my shoulder every single day I was in my surgery, for over five months.
That inflexibility of an IT provider caused three long serving members of my staff to resign. That is tragic.
This nonsense should not be happening when the NHS is such a massive purchaser of IT services.
Why are we not dictating to the IT providers what we want and need? Why are we beholden to them, not the other way around?
We need technology that works for patients. And makes our lives easier.
So, the NHS needs to take control.
In the past few years we have all seen an exponential rise in online providers of GP services. Some use symptom checkers or algorithms with Skype-type consulting as their main mode of care delivery.
CQC currently has 35 on its books in England, and after a rocky start for many, standards are improving generally.
Most are private providers, who are filling a niche in the market for people who don’t want to pay for full private general practice, but who are frustrated that traditional NHS general practice is just not fitting into their way of life, and who are prepared to pay a modest sum for the convenience of ‘a GP in their pocket’.
However, in the past year, a new NHS provider of online services ‘GP at Hand’ - has emerged, underpinned by the technology and financial backing of a large private provider.
As those of you from London know all too well, they are expanding rapidly and we hear that they already have over 32,000 patients signed up.
That’s largely people who work in central London, who have registered with them, and thus have been de-registered from their original GP surgeries.
GP at Hand are already actively seeking to expand their NHS offering into other major cities, using London as the hub, with outreach sites elsewhere.
And hundreds of excellent GPs are providing the clinical sessions for them, because they are, by all accounts, great employers, who pay well and value their employees.
The rest of the NHS needs to take note, to watch and learn, and up its game.
I have been publicly criticised this year for suggesting that their technology is impressive.
Well, ‘spoiler alert’, it is quite impressive. But we are still awaiting assurance that it is safe, and for that we need robust independent evaluation.
It is also intensely frustrating to traditional general practice as they seem to have found a way through the GP contract and regulatory frameworks, to set up something completely different for the NHS.
Something that challenges the ethical compact whereby the funding for fit and well people, helps pays for the sick and needy.
And so, the whole financial model of traditional NHS General Practice is now under threat.
Truly disruptive innovation.
I believe that this is our wake-up call – our shake up call. If we bury our heads in the sand and ignore this, we are fools.
And many patients are choosing rapid access to new tech enabled GPs over traditional consulting, giving up the trusted long-term relationship with their family GP in the process.
But of course, not every patient is encouraged to join, and all this risks widening health inequalities even further, as the younger and fitter are siphoned off.
Here in Glasgow, we are at the home of the Deep End initiative they really understand health inequalities, and so should we all as GPs.
This year we said farewell to Dr Julian Tudor Hart. If you don’t know who I am speaking about, please read his last ever interview in GP Frontline.
He was a special man, a Londoner who settled in the Welsh valleys as a GP.
A man of vision, of passion and strongly held political views. His writing was inspirational, his meticulous approach to care and note keeping was amazing, and he gave us the Inverse Care Law, published in the Lancet in 1971.
That says that the availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces.
I believe that with the right use of technology in the future NHS we can actually aim to reduce health inequalities, and counteract some of the adverse, social determinants of health.
But right now, those with the latest smart phone, those who speak English and live in cities, those who have high speed broadband, are being offered something that others are not.
We are currently seeing a widening of health inequalities, widening the digital divide experienced by rural communities, and the opportunity cost of all this is mounting.
We need our NHS to remain free at the point of need. To provide access for all. To provide opportunity for all.
I don’t want to be a GP just for a few people. I want to be a GP for all people.
With companies like Google and Apple leading the way in showing us what good can look like, then with enough resource the rest of the NHS could look impressive too!
This technology is not unique, it is not out with the grasp of the NHS. We could have genuine AI, not just fancy algorithms and Bayesian reasoners.
With a new Secretary of State in England committed to improving technology throughout the NHS, we have a window of opportunity to turn this around.
And so, I call upon the four governments of the UK to make the NHS the market leader for medical technology, so that we can deliver safe, effective, high-quality care for everyone.
I also call for the government to commit to having e-consultation facilities in every GP practice by 2022 and ensure that every practice across the UK has high-speed broadband capability.
We need technology that works for patients, makes our lives easier and is not lining the pockets of private investors at the expense of the NHS.
But there is another reality: robots don’t come cheap. Tech costs money. And for GP practices that are already on the brink, implementing new, good technology is simply unfeasible.
Most of us aren’t being propped up by wealthy venture capitalists, after all.
GPs on the front line just can’t afford the investment in technology.
Latest College research shows that of GPs who think that running a practice is no longer financially viable, almost a quarter tell us that technology costs are one of the reasons why, and that proportion has almost doubled in 18 months.
Give us the IT tools we need, in a way that does not put our existing services at risk, in a way that benefits all our patients and makes our working lives easier.
The Prime Minister earlier this year announced over £20 billion extra a year in real terms for the NHS by 2023.
That money should be used to ensure a 21st century NHS with a 21st century general practice.
That’s why we’re calling for £2.5bn extra a year in real terms for our profession in England, on top of what’s been promised through the GP Forward View.
That’s £14.5bn a year by 2021, bringing the share of the NHS budget general practice receives back up to 11%, To what it was in 2005, with proportionate increases here in Scotland, and in Wales and in Northern Ireland.
I now want to expand on the evidence side of things.
I challenge every doctor here that we all have an academic background. Medical school teaches the scientific method, to question, to seek out the evidence, to be evidence-based practitioners throughout our professional lives.
I mentioned a tech tsunami. That’s a destructive force of nature – a tidal wave. Well, actually it is a seismic sea wave to be correct about it, nothing to do with tides, but it’s caused by the displacement of a large body of water.
So, in a tech tsunami, harm is done by flooding of the ground with too much technology, some good of course, but also bad technology.
Our college motto, Cum Scienta Caritas: compassion underpinned by scientific knowledge.
We need rapid, independent, scientific evaluation of innovation, of new online consulting options, of software, of apps and wearables so that we can swiftly, safely and effectively establish which is the good new technology.
Mary Dixon-Woods talks about the Lovely Baby concept.
If you are unfamiliar with it, it goes like this, everyone believes their own child (or grandchild) is beautiful, wonderful, special. Our children are the best of us, and we invest in them emotionally.
Our innovations and ideas are our children and thus we all have lovely children. It takes an outsider to be objective and say, ‘hey, that really is an ugly baby.’
That really is not a safe innovation. That idea is actually widening health inequalities. That idea has superficial appeal but does not bear scrutiny.
Let us all beware of our lovely babies, and seek out independent, evidence-based appraisal.
I have been shocked by the response from some companies, whose reaction to constructive professional challenge is to descend into to bully-boy tactics and send legal letters, instead of engaging professionally.
We know of many instances of bad technology.
Errors and bugs in our own GP computer systems have repeatedly hit the headlines over the past few years, and Capita, let’s not even go there!
And of course, as social media regularly demonstrates to us, over-diagnosis and over-medicalisation by reliance on algorithm-based symptom checkers. Did you hear the one about the viral cough that was diagnosed as Multiple Sclerosis?
So, let’s get the basics of NHS IT right, before we spend millions on fancy tech.
Actually, first of all I would like a computer that takes less than ten minutes to log on. The ability to Skype without it cutting out every two minutes. And just one log-in process not seven!
It would be a start.
But let’s not be disheartened, there is a huge amount of great tech out there.
We now all have access to consistently high quality, online multimedia CPD. Digital interpretation of imaging is really taking off. And what about use of QR Pods to share information and keep it updated efficiently?
Please search our Bright Ideas portal for other great, safe ideas.
Have you looked at NHS Digital’s App Library recently? It’s fab!
Many of you will already be familiar with Couch to 5k and Active 10, both Public Health England endorsed, activity apps.
But what about Brush DJ? Two minutes of music to brush your teeth to.
Or my personal favourite, Chill Panda? Let’s relax and be more Zen like our furry, bamboo-munching friends.
And these are free, independently evaluated and fun…and we all need more of that in our lives!
In my introduction, I mentioned the 70th anniversary of our NHS, note the possessive: our NHS.
Additionally, this year we have celebrated: 100 years of the first women in the UK getting the vote; 400 years of the Worshipful Society of Apothecaries, from whom GPs evolved and who have supported our profession on its journey; and of course, it is the 50th anniversary of the College exam, our MRCGP Examination. My, how it has developed and improved into the world leading assessment it is today!
So, Happy Birthday NHS, Happy Birthday MRCGP.
Now, what about shaping the future of general practice?
I want GPs to be architects of our own future, not the passive recipients of the vision of others, which is why over the past few months we have been consulting with you.
If you haven’t yet fed in, there is still chance to do so. I need your input and Conference is a great time for that, a time to clear you head, see further and be creative about the possible.
Please visit the RCGP main stand in the exhibition hall during the breaks for opportunities to feed in.
There are of course already some very consistent messages emerging from GPs, patients and members of the wider practice team.
Continuity of care: yes, it’s not an outdated anachronism, providing continuity of care is valued by GPs and their patients – and it works. Barbara Starfield told us this decades ago, and Denis Perera-Grey, along with colleagues from Exeter published further confirmation just months ago.
Widening the primary healthcare team: we need to redouble our efforts to recruit to the profession and retain GPs, but also, we need to train up other healthcare professionals who have the capacity and skills to work with us.
We need offer greater flexibility in ways we deliver care: politicians and patients tell us loudly and clearly that they want us to be more flexible in when, where and how we offer appointments, but also our newer colleagues are telling us that they want to work differently for the benefit of their health and wellbeing.
And of course, back to technology: we need technology that works for all patients, makes our lives easier, and is not lining the pockets of private investors at the expense of the NHS.
So, that’s a taster of our vision. We will inevitably upset some groups if we are bold, but the future will happen with or without us.
My message is that we have to be architects of our own future.
We need to work with and learn from the tech tsunami and tame it by insisting on only embracing safe, evidence-based initiatives.
We need to assert our desire to deliver Enid-shaped care to all who need it.
We need to be flexible enough to look at our own entrenched Lovely Babies, and subject them to scrutiny, and where others demonstrate that there is a better way, we need to give it a go.
We need to share, to mentor, to support one another and not retreat into our own caves.
To do all this we need general practice to be valued, invested in and trusted.
I call upon our political leaders to give us the tools we need.
Give us the chance to tame the tech tsunami in a way that doesn’t put existing services at risk, in a way that benefits all our patients, and makes our working lives easier.
Give us the extra investment we all need and bring our share of the NHS budget back up to 11% right across the UK.
I want to be able to deliver great care to all my patients.
I want my surgery to deliver excellent care to our community.
And I want our NHS to value general practice, and nurture and care for our general practitioners, and recognise the amazing work they do, so that in 70 years’ time our NHS will be thriving and not just surviving.