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‘We’re not just dissatisfied, we’re furious’

This is the UK conference of LMCs, and so it’s right to begin by thanking my colleague chairs, of GPC NI, Scotland and Wales, Tom, Alan and Charlotte.  Without their friendship, guidance and support I would not be standing here.  As those of you who heard me speak yesterday will know, this is the last UK LMC conference at which Alan and Tom will be chairing their GP committees and we owe a huge debt of gratitude to both of these giants of general practice, not only for the work they’ve done in Northern Ireland and Scotland but for the huge impact they’ve had for GPs across the UK. They’ve still some months left to serve so it’s too early to say goodbye but now is the right time to say thank you.

Thanks too to my GPC England executive team, Mark, Farah and Krishna, and to the hugely gifted and hardworking BMA contracts, policy, communications and committee secretariat teams that literally work day and night, seven days a week, to support the work we do. They are the unsung heroes that we so often take for granted. Thank you to everyone.

As doctors we expect to work hard. It goes with the territory. It starts the day we walk in to medical school, although looking back I think some managed to enjoy the added attractions and distractions of university life a little more than others did, and looking around the hall I think there’s probably one or two here who may remember, or perhaps wish they could remember or even forget those days.

However, once you arrive on the hospital wards there is no doubting the workload you will have to bear and the hours of commitment you will have to dedicate to the task of learning and service. We want to do the best for our patients and we all go the extra mile to do that. But that dedication and willingness to work hard should not be exploited. One of the first media interviews I did was in the 1990s when I was a junior hospital doctor and I joined a BBC discussion programme about junior doctors’ hours. We were then regularly working one in three or one in four nights and weekends on call as well as working through the day and some were even doing one in two. It wasn’t safe then to have tired doctors walking the corridors day and night and it’s not safe now.

With shift systems and rota gaps in hospitals, and a recruitment crisis and unsustainable rise in consultation rates and workload in general practice, doctors today, old and young, in hospital and in the community, are being exploited by a system that relies on their goodwill, commitment and toleration of the unacceptable.  But it is unacceptable, and we should call it what it is.  It’s dangerous, leads to patients being put at risk and it cannot go on.

We know all too well what happens when a doctor finds themselves working in a system that does not take seriously the need to reduce risks, in a system that does not learn from mistakes but looks to scapegoat or punish those who make them. We all know that, even in the most tragic of circumstances, when our heart goes out to and yet can never truly understand the grief of family members, and the doctor concerned can feel broken and devastated, lessons still can and must be learnt, so as healthcare professionals, and as a healthcare system, we try our best to reduce the risks for the next patients we see and treat.

Jeremy Hunt was right when he said that he was “deeply concerned about the possible unintended implications for learning and reflective practice” about the GMC’s decision to challenge a finding of the Medical Professionals Tribunal Service, and he went on to say that “for patients to be safe, we need doctors to be able to reflect completely, openly and freely about what they have done, and to learn from mistakes”.

But just as importantly we need a system that does the same, that not only learns the lessons but does something about it and puts in the necessary resources and workforce to reduce the risk of doctors and other NHS staff from ending up in dangerous situations.  For without change, the next time it could be me pursued by the GMC, it could be you standing in the dock, it could be any one of us scapegoated by an unsafe and overwhelmed system. It’s not only unfair, it’s unjust and the system must change.

It’s why it’s important for GPC across the UK to do what we can to reduce risks. It’s been the basis of the contract changes in Scotland, with reduction of risk and managing workload at the heart of the plans that have now been agreed between the Scottish Government and SGPC. It’s why GPC Wales successfully secured a suspension of QOF for a second year, sensibly prioritising the sick rather than bureaucracy when we were all doing our level best to cope with the extraordinary workload levels brought on by the winter and a flu outbreak. It’s why in England we’ve produced our workload management plans1 to make the case for safe capacity limits and which empowers practices to work together to deliver this, and it’s why in Northern Ireland funding has been secured for pharmacists working through federations and linked to every practice.

Despite a year without politicians, and the challenges of getting decisions made, NIGPC has managed to secure a contract deal for this year. It helps to build on the work they’ve already started by investing in pharmacists who will not only help reduce workload pressures in practices but also help to reduce untoward incidents from medicine related errors that can all too often lead to hospital admissions and even death. It seems self-evident that every practice in the UK should have the support of a pharmacist as part of their team.  It’s part of the plans in Scotland and some enlightened CCGs in England have been working to do the same, using recurrent funding from CCG budgets to supplement the short term and inadequate funding in the GP Forward View scheme.  Every hospital ward has a linked pharmacist, it’s about time every practice had one too.

But we shouldn’t stop there, for in this time of prolonged austerity with more and more people suffering from the consequences, every practice is dealing with a rising need from their patients with mental health problems, and yet in too many areas the access to IAPT and other talking therapies is becoming harder and longer to access, not easier or shorter. Patients are waiting months2 on end before they can access the care they need but we know too that mental health services are impacted by the same problems as GPs, with too few staff with too little resource trying to do the best they can for too many people.  We need the promised 3,000 additional therapists in England and more besides, but we also need them linked to our practices.  We need to be rebuilding the primary care team in and around our practices.  Whether it’s across a cluster of practices in Wales, through federations in Northern Ireland, health boards in Scotland or locality networks in England, we all have the same need for an expanded and resilient community team that works with us and for the benefit of all our patients.

One of the rate limiting factors for building up a resilient team is the problem of indemnity. Well-designed schemes struggle to get going because of the difficulties of agreeing how indemnity cover will be provided.  But for GPs it’s even worse, as we, almost uniquely in the NHS, have to effectively pay an indemnity tax of many thousands of pounds just for the privilege of working. And then we have the ridiculous situation in England of a helpful winter indemnity scheme for out of hours being cut from April when it is still desperately needed. Is it a surprise then that so many junior doctors are put off choosing general practice as a career, that so many GPs worry about the additional costs of doing out-of-hours shifts, or that so many senior doctors are looking to reduce their clinical commitment or leave altogether?

If we want to reduce risks to the system we have to deal with the issue of indemnity.  It’s why in England the Secretary of State’s commitment to introduce a state-backed indemnity scheme by April next year is so important, and it’s good to see the government in Wales making similar commitments. All we ask is for equality with our colleagues in hospital.  It cannot be acceptable for a GP to be working alongside a consultant colleague in the same community service, and for one to pay indemnity tax of many thousands of pounds whilst the other has their indemnity covered by the NHS. A comprehensive system, that covers all GPs – locums, salaried and partners – as well as the staff who work in our practices, has to be put in place, and we will work with government to make sure this happens.

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If we want to reduce risks to the system, then we also have to deal with the problems of premises.  This is now one of the biggest problems facing practices across the country. Practices are handing back their contracts as their business becomes unsustainable and they can’t recruit GPs, simply because of their premises. Commissioners are failing to invest or cover the rising cost of rental charges demanded by NHS Property Services. Trainee GPs are steering well clear of any partnership offers and choosing to be salaried GPs instead or taking up locum roles, simply because of the risks of premises ownership or being tied in to long term leases.  We don’t expect a junior doctor or consultant to buy in to the bricks and mortar of the hospital building, and yet all too often there is still a need for a new GP to do that if they want to be a partner in a practice.

The deal in Scotland shows that something can be done about this.  It is possible for the NHS to share some of the risk.  With commitment, imagination and yes, some resources, it is possible to stabilise practices that are on the edge of closure.  Getting agreement on the premises cost directions in England after three years of discussion has been difficult, but we are under no illusion that this will solve the major problems facing so many practices, which is why we’ve been calling for a fundamental premises review.  The solution found for Scotland may not be replicable in every part of the UK, but the need to take the issue seriously and reduce the risk for GPs cannot be overestimated. Commissioners simply burying their head in the sand and hoping the problem will go away is a sure certainty to result in more practices collapsing and more GPs walking away.

Reducing risks will go some way to reinvigorating the partnership model and the independent contractor system that this conference has consistently advocated and which we will be debating again shortly.  We’ve struggled because of a decade of underfunding that has tested many practice partnerships to breaking point. But as the NHS approaches its 70th birthday we should be proud of the fact that it’s resilient practice partnerships that have been the foundation on which the rest of the NHS has been built.

It’s our direct connection with local communities, the fact that business owners are on the shop floor every day seeing and treating people face to face, our ability to independently advocate for our patients and stand up for them when needed, our resourcefulness and adaptability that can cope with all manner of changes and challenges, and even survive NHS England’s abject failure over more than two years to sort out the shambles that they created when they privatised our back office service and left us with Capita’s Primary Care lack-of-service England, which is why we have had to empower practices and GPs to seek legal redress for the impact this failure is having on them4. 

The partnership model enables all partners to have a stake in the organisation, to have a voice and shape the services they provide to their patients. It creates an environment of colleagueship and mutual support for salaried GPs and locums. It provides for flexibility to enable portfolio working and for GPs to take on different roles at different stages of their careers and it provides the building blocks for effective locality working.

The registered list, on which our model of general practice depends, might be under threat by the inappropriate use of out of area registration arrangements by a service in London that’s cherry picking relatively young healthy patients. As the editorial in the BMJ last week said, “we run the risk of prioritising access for the healthier over comprehensive generalist care for the sicker”. This is not what the NHS should be doing.

Nevertheless, we know that our independent contractor status and GP partnership model are good for doctors, our staff, patients, communities and the wider NHS. Valuing and building on this is a central goal of our Saving General Practice report and it’s why we’re pleased the government in England have listened to us and initiated a project to reinvigorate the partnership model, and why the changes in Scotland have the independent contractor partnership model at their heart.

But no partnership can survive if it’s starved of funding.  There’s an old story of a pharaoh in ancient Egypt who had a dream predicting seven good years followed by seven lean years.  Well GPs haven’t been dreaming, we’ve had a living nightmare.  The reality for GPs is that we’ve had a decade of lean years to contend with, and enough is enough.

Is it any wonder that the recently published British Social Attitudes Survey5 showed a fall in patient satisfaction?  And what are patients dissatisfied by – staff shortages, long waiting times, government reforms and a decade of underinvestment. Well, as usual, GPs agree with their patients. But we’re not just dissatisfied by what’s being going on over the last 10 years, we’re furious.

The Treasury have used excuse after excuse not to fund general practice properly. We’ve had the international banking crisis in 2008 which limited the funding to the NHS, years of austerity, and now because of their uncertainties about the financial consequences of Brexit, rather than investing an additional £350m a week in to the NHS as everyone was promised by the leave campaigners, the reality is that Brexit is currently hurting the NHS, leaving it without the funding we and our patients desperately need.

Even NHS England’s own evidence to the DDRB this year contains a table that shows 8 consecutive years of pay cut after pay cut for GPs since 2007. It’s only in the last couple of years that we’ve secured a 1% rise but even that is a cut in real terms. It’s why this year we have not accepted a further below inflation rise. It’s why we are calling for an end to this attrition in GP pay that is having a major impact on GP recruitment, retention and morale.  It’s why we have no doubt, and make no apologies, GPs deserve a pay rise and it’s time the UK government provided for it.

But we are not just seeking a pay rise, more importantly general practice needs properly funding. To meet the growing needs of our patients we need new recurrent funding to expand our workforce both in and around the practice. We need recurrent funding to lengthen our consultations so that we have time for our patients and reduce the risk of errors and mistakes. We need recurrent funding to invest in our IT and premises infrastructure. We need recurrent funding to develop the services we are able to offer to our patients in the community. We need recurrent funding to support locality working. And we need recurrent funding to turn back the tide on patient dissatisfaction and low GP morale and deal with the workforce and workload crisis that is impacting patients’ access to high quality care.

In some parts of the UK governments and commissioners have woken up to the need to invest in general practice and community based services. And yet all too often all we get are fine words but little action. In England the NHS’s revenue will grow by just over £2bn in the coming year, and yet despite the rhetoric the vast majority of that will be spent in hospitals and far too little in the community.  If general practice fails, it will not be because we failed to warn those who could make a difference.  The time to act is now.

GPs around the UK are doing their best for their patients despite the huge challenges they face day in and day out. GPC England, Northern Ireland, Scotland and Wales are all doing our best to work on your behalf, to reduce the risks, to secure the funding and expand the workforce to help practices and individual GPs – partners, salaried and locums – to meet those challenges and reduce workload to safe and sustainable levels. As GPC UK and LMCs from across the UK, we are stronger together. We can, and we will, stand together and together we will make things better.