Dr Chaand Nagpaul: 'GPs must resurrect our Darwinian survival instinct'
The GPC chair tells GP leaders that the task ahead is ‘formidable’, in his speech to the LMCs Conference
Since we last met a year ago, the NHS has been paralysed by the vote for the UK to leave the European Union. Far from the pledged investment of an extra £350 million per week –audaciously plastered on double decker buses - the reality is we’ve been cheated with the opposite of a deep freeze in NHS spend, continued savage austerity cuts, and with government turning a blind eye to the spiralling pressures affecting the entire health and social care system, in which even the NHS constitutional promise of the 18 week target is being allowed to be breached.
GPC across all four nations has had to work with this financial brick wall, and the devolved nation chairs will later feedback on how they’ve met these challenges. In England, we had the added dimension of a breakdown in the relationship between the BMA and the government last year during the junior doctor dispute. Despite these strait jackets, GPC has worked hard to deliver change for the profession. We secured NHS England’s acceptance to take forward our Urgent Prescription for General Practice. This paved the way for our 2017/18 contract negotiations, in which we secured an end to the avoiding unplanned admission enhanced service, with the entire £157 million put into core funding, and freeing practices from the bureaucracy of chasing futile statistics of care plans. We began talks to protect practices from rises in CQC fees, but went further and delivered full reimbursement of CQC costs. We secured payments for rises in indemnity fees which unfairly tax us to provide care. Practice expenses for the first time were itemised to the detail of actual costs of the time consuming work we undertake, from bagging notes to completing the workforce data census.
We negotiated significant improvements to GP sickness cover and put many historic wrongs right. Practices are guaranteed payments ending the uncertainty of discretionary reimbursement, we’ve removed list size criteria and pro-rata payments and increased the maximum sum payable. We have enabled payments for internal cover rather than having to use external locums, and unlike insurance premiums this does not disadvantage any GP based on their previous health record. This provides practices with financial security of up to £66,000 per annum per GP against the unpredictability of long term absence and will reduce for many the costs of sickness insurance.
The global sum has increased to £85 per head, which is protected money that cannot be picked off . This is not enough but we’ve come a long way from four years ago with an imposed contract when the global sum was £66 per head, and we’ve also ended seven directed enhanced services in this period with money transferred into core budgets.
Despite these contract improvements, the plight of general practice remains parlous and on the brink of collapse. We’ve always been clear the crisis in general practice cannot be addressed by these annual contract revisions. Indeed, the bigger issue is the avalanche of work piling up from outside our contract which is either inappropriate or unresourced. Also that we have wider pressures such as being several thousand GPs short due to shambolic workforce planning a decade ago. which resulted in hospital specialist numbers rise at 3 times the rate of GPs. We’re in effect paying the price of disinvestment in general practice at a time of plenty, and are now trying to make up for it at a time of empty.
There’s sadly no fat in other parts of the system to transfer to general practice, with a financial crisis spanning community, hospital and social care all of which adds more work onto general practice. The real solution is a political one – in which politicians must end their callous disregard of the health needs of citizens in an NHS that shamefully trails Europe in its funding, numbers of doctors and infrastructure. The only solution is for government to increase NHS funding to adequate levels, in which general practice receives a fair and larger share. That’s what voters need to demand from the coming general election, and why investment in general practice is one of the five key asks in the BMA election manifesto
Meanwhile, GPC’s strategy has been to ensure survival of our discipline within this barren landscape. When over eight in ten GPs say they can’t provide safe, quality care, and the government cannot magic up the thousands more GPs we need, our emphasis has been on managing workload and demand. We know that one in four GP appointments is potentially avoidable where patients could more appropriately have seen another professional, patients who could have self-cared, or appointments taken up for completely bureaucratic purposes. If we could liberate these one in four appointments, that would in effect increase GP capacity by 25%, far greater than the political mirage of 5000 more GPs. It’s therefore a no-brainer that the immediate priority for the NHS must be to ensure that precious GP appointments are not misused, recognising that every wasted appointment is an appointment denied to a sick patient. Unlike meaningless four hour targets, what we need is a concerted national target to eliminate inappropriate GP workload freeing us to care for patients who need to see us.
Key to this is addressing bureaucratic and unfunded secondary to primary care shift – a theme that’s dogged LMC conferences for decades. As a result of GPC lobbying, for the first time contractual changes were introduced in English hospitals last year to specifically stem inappropriate workload transfer into general practice – with obligations on hospitals not to send patients back to their GP after missing a clinic appointment, to make internal referrals for related medical problems rather than telling the patient to see their GP for a new referral, and to communicate hospital test results to the patient directly.
For 2017/18 onwards, as a direct result of GPC’s Urgent Prescription, we secured from NHS England further contractual changes that hospitals must directly respond to patient queries and not ask patients to see their GP instead; to provide the full duration of a fit note until return to work rather than asking the GP to top it up, and contractually prohibiting the transfer of shared care arrangements without explicit GP agreement. And we’re having further dialogue on urgent prescription proposals regarding prescribing across the interface for next year. These changes are significant and symbolic, as they represent a new and unprecedented national policy to end the damaging impact of workload dump onto GPs when we should be treating patients instead
These changes won’t happen overnight or automatically -we need to reverse a culture spanning decades which has been ingrained into the mindsets of hospital secretaries to appointment clerks.
That’s why GPC England has provided practices with template letters to push back on breaches and report these to both the provider and their CCG. Remember CCGs as commissioners are directly responsible for contractual delivery by hospitals, and practices, supported by LMCs, must as members in turn hold their CCGs to account. We must all play our part to use these hard won contractual levers to finally consign to history the demeaning suffix “go and see your GP” as the backstop for every system failure in the NHS.
And while there’s no doubting the stresses on hospitals, ministers must grasp that the biggest risk to hospital pressures is reduced capacity in general practice. I previously calculated that a 6% reduction in GP capacity would double numbers of patients attending A&E if they went there instead. That’s why NHS England’s proposals to move GPs out of surgeries and into A&E departments totally misses the point. This will be wholly counterproductive by reducing GP capacity further. We need more GPs. They need to be working in general practice. Can we put it any more clearly to the government?
Our BMA survey showed GPs felt patient self-care to be critical to managing demand, and is also an urgent prescription priority. We’ve been formally working with NHS England on a national campaign, including developing pilots to demonstrate how self-care initiatives can reduce GP appointments.
We’ve also strengthened our support to practices to take control of their own workload. Our Quality First webpages have expanded, providing tools to push back on inappropriate work, and guidance on new ways of working and use of technologies-and has had 44,000 unique hits in the past 12 months. Responding to last year’s conference motion, we developed and circulated a national list of enhanced services to LMCs, to serve as levers for practices to either decline non-core work or make sure it’s properly funded.
Moving onto the GP Forward View, we know it won’t in itself solve the crisis in general practice, and it’s not an adequate funding package within a bankrupt NHS. However it’s our duty to hold NHS England to account to ensure that this promised funding reaches GP practices and is not squandered. That £2.4 billion is actually recurrently delivered by 2021, and that the £508 million transformation monies are actually spent to support practices that need it desperately. We’ve throughout the year monitored NHS England’s balance sheet to ensure resources are being spent.; I set up a dedicated LMC reference group which has for the first time brought regional LMC representatives face-to-face with the top tier of management at NHS England. This means that that national managers can hear first-hand from LMCs about local realities rather than only from enthusiastic clinical leaders. We’ve also set up a GP forward view policy group to support LMCs and receive feedback via monitoring templates. This has highlighted the frequent disconnect between central policy and local implementation, and we’ve acted swiftly on any errant CCG or area team behaviour. We’ve critiqued the GPFV in our “one year on” analysis, which using feedback from LMCs, showed that while money and support is beginning to reach practices, it’s unacceptable that this has been patchy across the country with delays and hurdles resulting in a postcode lottery of support to the very practices in the greatest of need.
We therefore last month held an extremely successful GPFV implementation conference for LMCs to support practices to claim their entitled support from 2017/18 onwards.
Remember that GPFV delivery occurs locally via CGGs and local teams, and this is why LMCs are key in local monitoring. CCGs who are faced with hospital deficits must show leadership and remind their masters at NHS England of the blindingly obvious fact that starving general practice of resources will only worsen hospital deficits.
On GP access, we’ve secured changes to the irresponsible political pretence that we can provide a consumerist routine seven day service when we can’t run the NHS in the winter without support from the Red Cross. We’ve influenced the GP forward view proposals to no longer require 8-8 opening on weekends, and for local commissioners to decide based on local needs - we must demand that CCGs use this flexibility and not waste precious NHS resources to pay GPs to sit in empty surgeries on Sunday afternoons.
We’ve also influenced that the access monies can now be spent to support in-hours GP capacity and pressures, as well as for urgent appointments – and can therefore be used to develop GPCs’s safe working proposals to enable practices to put limits on workload and refer overspill patients to locality hubs. We must exploit these hard fought changes to ensure that this resource supports general practice workload and not political ideology.
The individual practice unit has become frighteningly vulnerable, with one in ten practices surveyed saying they’re not sustainable and we’ve witnessed record numbers of practice closures- not surprising with one in three practices unable to fill GP vacancies. Even a seemingly secure practice is just one partner away from retiring to set off a domino effect which could lead to collapse. That’s why it’s critical that resilience monies reach the most fragile of practices in a timely proactive manner without hurdles.
GPC also believes that key to achieving practice sustainability is for the profession to work together with and for each other, and to create collaborative resilience. Etched in my memory when I became a GP was our gruelling unsustainable contractual twenty four hour responsibility, 365 days a year – we survived this by GPs themselves creating an out of hours cooperative movement from a modest out of hours allowance, and which transformed our lives
We need to revive this spirit of collectivism in today’s desperate times, and this is why we held our recent “working together to sustain general practice” conference for LMCs this year, in which we heard of bottom-up approaches from super partnerships to federations, supporting the continuation of the practice-based model of general practice, with case studies of reducing GP workload, managing demand and even enabling practices to move to 15 min consultations. The fundamental ingredient for success was that these models were driven by the innovation of GPs themselves, not top-down policy, with the independent contractor status at its heart- drawing upon the social entrepreneurialism of GPs.
GPC also succeeded in changing NHS England’s original MCP proposals for an alternative GP contract, so that now practices can retain their national G/PMS contract and gain from multi-professional working.
Collaboration requires resources for headspace, backfill, and project management and why we’re insisting that the GP forward view transformation monies of £3 per head are made available in every CCG, since this holds the key for us to transform and sustain as we did in the 1990s with mutifunds and GP cooperatives.
Many practices are also at threat of financial collapse from brutal hikes in service charges from NHS Property services. The government must intervene to protect practices from a landlord that is part of the NHS, but insists on destabilizing those very tenants providing essential NHS services, with harrowing increases in charges that run into six figure sums without explanation nor justification. To address this issue, we have set up a GPC task group with LMC representation to robustly challenge this
The past year has also demonstrated with stunning clarity the absolute folly of outsourcing NHS services to the private sector, with Capita completely underestimating the task in hand, and importance of organisational memory that underpins the NHS. You can’t run the health service using this kind of cost-cutting commercial tactics. This has adversely affected quality, services and safety and yet has shamefully escaped the regulatory vilification that GP practices would receive from CQC inspections for a fraction of such shortcomings.
We conducted a major GP survey last November, since we must design general practice on the aspirations of everyday GPs including the GPs of tomorrow. We know that GPs increasingly want to work in different ways - some wanting partnerships, other salaried jobs, freelance work, portfolio working, through to specialist interests. The growth of the sessional workforce must be recognised as a legitimate positive career choice, and I’m proud of the excellent work of our sessional committee led by Zoe Norris. We must also create models of general practice that embrace this diversity, so that we have local communities of GPs working together with common purpose, with aligned incentives regardless of contractual status. And remember that to the patient in the confines of the consulting room, it doesn’t matter a jot whether you’re a sessional or contractor GP when they place their trust and care in your hands, and why we must create parity of esteem for all GPs.
This is therefore a time for professional unity. We’ve seen shameful attacks on the worth and value of our locum workforce. Let’s not forget that today’s conference wouldn’t be happening today if it wasn’t for locum GPs seeing our patients while we’re convened here, and which is why we must support this essential part of our workface that props up general practice daily. But equally let’s not forget the devastating reality facing partners – a shrinking pool taking on ever increasing workload and responsibility- our survey showed partners worst affected reporting unsustainable workload twice the rate of salaried GPs, and six times worse than that of locum GPs. Repeated surveys including DH figures show that up to four in ten partners intend to retire in the next five years. Conference, the collapse of the partnership model will have dire consequences on all of us, and sink the entire profession in the process, with the prospect that we’ll all in the future be at the mercy of working for large providers, who are likely to have values and a commercial ethos at odds to everything we stand for. You need look no further than the blanket approaches adopted regarding IR35 serving as a warning of the real risks to our working terms and conditions.
The locum workforce therefore needs the continuation of the partnership model just as much as partners need locums, and we must to pull together, quite literally, to sustain a future for general practice.
GPC has worked hard to make the crisis affecting general practice visible to the public and patients. Three years ago I said on this podium that the only crisis reported in the NHS was that affecting hospitals. We’ve come a long way in tangibly raising public, media and political awareness that there is also a crisis in general practice, on the back of our urgent prescription campaign.
The Prime Minister’s shameless attempt in January to scapegoat GPs for hospital pressures was an insult to a profession already on its knees keeping the NHS afloat. We fought this robustly on the front foot exploiting the free advertising on prime time national TV and radio for a whole weekend to deliver our “strong and stable” message – not the Prime Minister’s- that general practice is suffering a crisis of workload, safety, and workforce , and we exposed that that this was nothing other than a desperate attempt by government to deflect from its failure to adequately resource and run the NHS properly,
We have also implemented major GPC reforms this past year including creating a separate GPC England. I thank GPC members for their vital contribution in securing positive changes amidst this organisational change. We’ve developed a team of policy leads, who’ve done a sterling job in creating a wider and diverse leadership to support a smaller executive. Whilst the reforms have recognised the reality of devolution, the four national GPC chairs remain in regular contact to maintain a pan UK approach to relevant policy, and with shared learning and support. I’d like to formally thank my friends and colleagues Charlotte, Alan and Tom for their leadership in addressing their respective national challenges which you’ll hear about later. I’d however like to make special mention of the plight of our colleagues in Northern Ireland, facing a lack of functioning government, hung out to dry with no signs of investment, strategy or support, and to say that the rest of UK GPs are completely behind you in your actions to protect yourselves and patients.
We’ve also provided support to English LMCs to unprecedented levels, supporting regionalisation with central oversight and strategy, and held two full house LMC facing themed conferences this year. We’ve gone out to the field, holding more roadshows and meetings with LMCs, and I pay tribute to the exemplary hard work of so many LMCs supporting GPs with leadership and vision during these troubled times. We’ve increased our communication to LMCs to record levels, with guidance, updates, and regular requests for feedback. This partnership between GPC and LMCs is more important than ever before, and each of us can only be maximally effective by working together in synergy, and with mutual respect with our common endeavour to see general practice survive.
Conference, the task ahead is formidable. Since rebuilding general practice after a decade of neglect won’t occur overnight, and there’s no single magic bullet for our multiple pressures. I draw strength from becoming a GP on the cusp of the 1990 contract, when the profession suffered an imposed contract that tore apart our core values – yet we fought our way through it. I was a seasoned GP in the desperate years before the 2004 contract which also led to a special conference when general practice was on the brink of collapse, and we came through that trough too.
We did so due to our adaptability, determination and resilience. Like before, we can- we must- get through these troubled times, with confidence and self-belief that the service we provide to one million patients daily trounces all the empty promises of politicians. In which even recent surveys shows that patients continue to trust GPs at the highest of levels, despite our constraints.
We must therefore resurrect our Darwinian survival instinct, and stake our claim with our patients and the public to demand that the general election delivers a government that will fund the NHS properly - to plug the £10b gap compared to our European counterparts - and give general practice the resources to do justice to our profession, our discipline and the patients we care for.