Dr Richard Vautrey: 'We cannot overload PCNs with work'
BMA GP Committee chair Dr Richard Vautrey's full speech to the 2019 England LMCs Conference
What a year! For the last 12 months our parliament, our politics and our nation has been dominated by Brexit. We have had a year of deal or no deal, a year of parliamentary deadlock, and a year that saw the end of one Prime Minister’s government and the beginning of another. And now we find ourselves in the midst of a general election. And so to get anything done, to get any decisions made and ratified has been phenomenally difficult.
And yet, despite all the political turmoil, we have done what you tasked us to do. This time last year we had just heard that the then Prime Minister had announced that £3.5bn of the promised £20bn for the NHS would be spent on primary and community care. In the end we secured £4.5bn and an “NHS first” commitment to increase the share of NHS spending on our vital services.
This time last year you called for an end to annual contract changes and so we secured a five-year contract deal that delivers nearly £1bn to core funding for practices, and an additional £1.8bn of funding through PCNs, as well as crucially providing practices with much-needed stability and certainty.
This time last year you called for protection from the threat of the Integrated Care Provider Contract, which threatened to undermine the fundamental nature of our contract and service. And so we’ve achieved a deal that retains, strengthens and builds on our national GMS contract, that recognises the strength of the independent contractor status and partnership model, and places us as leaders of a potentially reinvigorated and reconnected community care team.
And this time last year you were worried that the promises we made about a national indemnity scheme would not be realised and would instead for decades to come put GPs at risk of being overwhelmed by unsustainable rises in indemnity payments. We were repeatedly told we could not do it, that it would not happen. But we stuck to our task, and for every locum, salaried GP and partner, as well as for the countless thousands of staff who work in NHS general practice, we delivered a state-funded indemnity scheme for all of you.
Rather than the “here today and gone tomorrow” short-term schemes we’ve seen in the past, our contract agreement provides guaranteed recurrent funding for a much-needed workforce expansion, it strives to move away from tick boxes to quality improvement, and it lays the foundation for real IT investment and development so we can challenge organisations like GP at Hand and, rather than provide a service just for the cherry-picked healthy and wealthy, we will continue to deliver a comprehensive service, rooted in communities, that meets the needs for everyone.
A risk that those who don’t fully understand PCNs will see them as just another NHS organisation
We concluded our negotiations in January. The sceptics said it would be impossible to get PCNs established in every area of the country, that the funding wouldn’t materialise or that GPs who fell out over parking spaces 30 years ago would never be willing to work together. Well the sceptics didn’t know GPs like we know GPs. For we know that GPs are dynamic and innovative. GPs will rapidly rise to a challenge and seize the day. GPs will make systems work for the benefit of their practices and their patients.
Within months, almost every practice was signed up and virtually every area had a PCN in place. It was a remarkable achievement and showed politicians, policy makers and the rest of the NHS what general practice can do. And so I want to publicly acknowledge and say thank you to over 1,250 clinicians who have taken on the role of clinical director, GPs and others stepping forward to lead and shape services across the country. At our first PCN conference in June it was great to see such a diverse group of leaders, many of them taking on a role like this for the first time.
It’s vitally important that we support and protect clinical directors. There is clearly a risk that those who don’t fully understand PCNs will see them as just another NHS organisation and overload them with all the problems no one else has been able to solve for decades.
Indeed, earlier this year we launched a survey of clinical directors, and preliminary results have found that almost half classed their own workload as unmanageable, whilst nearly two-thirds said the same about practice workload.
This is why you as LMCs have a crucial role to play in providing them support and offering them protection. After all, the same survey found that their relationships with LMCs were rated the most highly of all local bodies.
So, you have an important lesson to offer and a word to teach them. You need to help them to say “No”.
There is much that practices working through PCNs can do, there are real opportunities for us to seize and make the most of, with clinical directors telling us they are confident in providing strategic leadership and influencing relationships across the network and the wider local healthcare system.
With the right investment and support we can make the system work better, we can improve services for our patients, we can reduce our workload burden but we must not allow anyone to overwhelm us or our clinical directors and when it’s right for our patients, our practices and our sanity we and they must say “No”!
When it’s right for our patients, our practices and our sanity, we and they must say 'no'!
This is why the BMA has invested in providing bespoke support and services for PCNs and clinical directors in particular, and I want to thank all those in the BMA staff team that helped do this for us as well as for all the other support they have given us throughout this year. We are listening, and while the full clinical directors survey results will be published in the new year, we will also continue to engage with LMCs and all GPs to hear your views on how PCNs are affecting your day-to-day work.
I also want to thank my executive team of Mark, Krishna and Farah who worked so hard not only on delivering the contract deal but on countless other issues throughout the year too. And thanks too to our policy leads, many of whom were appointed in the summer, alongside our new sessional GP committee and trainees committee chairs. It’s great to be working with them all.
You will know as negotiators for your LMCs that negotiation is the art of the possible. It requires working with others and developing an agreement that is acceptable to both sides. It needs an understanding of the wider political landscape. And it means recognising gains that balance or outweigh other changes being made.
So, none of us are under any illusions that the contract deal solves all our problems; far from it. It’s a start, but only that. We still have a huge task to do to reduce unsafe workload burdens, to change the ridiculous pension arrangements that penalise hard-working GPs, to resolve problems with premises, to deal with the repeated failings of Capita, to attract and retain more GPs and above all to improve GP morale. These are all huge issues that impact GPs and practices day after day and we will not rest until we have resolved them.
But we also need to recognise when we are the ones that need to change, when we could learn and do better. The Romney Report, commissioned by the BMA following serious concerns raised by female GPs, should not only be read by all of us, but should be acted on by all of us. Every GP and every member of staff, whether in the BMA, LMCs, practices, out-of-hours organisations, CCGs or any NHS organisation both locally and nationally, deserves dignity, courtesy, kindness and respect. No one should be subject to discrimination whether consciously or unconsciously and all should be enabled to play their full part and use their skills to the best of their ability. I’m committed to doing this within GPC and I hope every LMC will do so too.
We not only need to challenge discrimination and discourtesy when we see it, we also must, and we will, fight injustice. It’s simply not acceptable that practices are not properly supported to respond to the vitally important area of child safeguarding and so in August we launched an application for judicial review in Northamptonshire challenging the failure to make any financial provision for child safeguarding services provided by GPs.
It’s not acceptable that dispensing doctors are excluded from parts of the Government’s consultation on drug reimbursement reforms and so we are challenging the department on that to enable the voice of dispensing doctors to be heard. And it’s not acceptable that practices in NHS Property Services premises are left to pick up the cost of an unjustifiable hike in charges and so we will very shortly be lodging a legal test claim in court for five practices which, if successful, would provide a template for other GP practices to defend unlawful claims for service charges by NHS PS.
We must and we will stand up for GPs and take legal action when it’s necessary to defend our profession.
But there’s much more that we need to do. It’s a shame that government, despite its obsession with, and paralysis caused by, Brexit, has singularly failed to solve the daily problem of medicines availability. How can it happen so frequently that in one of the world’s leading nations that it’s not possible to obtain commonly used HRT products for our patients? How can it be possible that important antidepressants, anticonvulsants or hypertensive medication are not available? Instead, we have ridiculous penny-pinching prescription switch software clogging up our computer systems and slowing us down, when what we really need is serious action to sort out this medicines availability once and for all, so we can actually prescribe what our patients need.
Whilst these fights continue we are making progress in other areas. Since 2006 we’ve seen the joint impact of austerity and a deliberate policy by governments to push down GP pay, one of the key reasons that led to the recruitment and retention crisis we face now. But after consistent pressure, lobbying and negotiation we’ve now reversed that trend with the latest figures for 2017/18 showing we secured pay rises of above 3% for both contractors and salaried GPs, and although it doesn’t take into account the loss through inflation, we are at long last heading in the right direction.
And, even though GPs and their practice teams remain under huge pressure, don’t let anyone tell you that practices are not delivering for their patients, with CQC’s second annual report showing yet again that general practice is top of the pops, with 95% of practices rated as good or outstanding, an achievement that in itself is outstanding and should be celebrated by all of us.
But that achievement is still without receiving the level of resources necessary to match the growing needs of our patients. After starting to see a long-needed upward trend in the proportion of funding the NHS spends on general practice, the most recent figures suggest that change has stalled at 8.1%. This is simply not good enough, and whilst the Long Term Plan commitment to address this is important, it will count for nothing if CCG financial pressures lead them to disinvest rather than invest in GP services.
Just a few weeks ago the GMC joined many others before them and highlighted the impact of this historic lack of investment, with 50% of GPs, as compared with 26% for other doctors, reporting that they often felt unable to cope and that they worked longer than their expected hours. This workload pressure, compounded by the continued fall in GP numbers, is putting our patients at risk. It’s good that so far political parties have listened to us and not include counter-productive access targets in their election statements, as a strategy of just beating an already overwhelmed workforce harder will not improve the service we can deliver. Instead political parties must prioritise protecting patients and GPs’ sanity, and that means a commitment to three things: investment, investment, investment.
We will hold NHS England and NHS Improvement to account to deliver what they’ve promised, but we will also work with them to take urgent action to mitigate the impact of the workforce crisis caused by punitive pension tax rules, with hard working GPs being unfairly penalised for the hours that they care for their patients. Many of you will have seen reports of proposals earlier this week, which could fund the annual allowance tax charge that GPs would be liable for this year.
We will hold NHS England and NHS Improvement to account to deliver what they’ve promised
However, let me be clear, whilst proposals such as this could be a short-term fix for a problem the government created, they are not a long-term solution. What we really need is for any new government, whatever their colour, not just to make vague promises at election time, what we need is for them to tackle the pension tax rules once and for all, so that all doctors can spend their time focusing on their patients and no longer worry about the financial risk to them and their families of caring too much.
In the coming years we have a chance to show what GP leaders and general practice can do. With confidence we can take greater control of what is happening in our areas, with vision we can reconnect our fragmented primary and community healthcare teams, with collaboration we can support each and every practice, with increased investment we can improve services that have been stretched to breaking point and with boldness we can seize every opportunity and restore our great profession and service.