Mr Chairman, Conference
We meet today at a critical point for the NHS and for general practice. It is no exaggeration when I say: a signal has been passed at danger – the NHS is under real threat. All of us but the politicians can see the buffers fast approaching. When is the driver going to pay any attention to any advice? Mr Hunt, start listening now.
As we have over the last 65 years, doctors, nurses and other NHS staff can work together to find a way through the current challenges and continue to provide more and better health care, free at the point of delivery, accessible to all. But not if the government insists on denigrating us and using the NHS as a political weapon as it has increasingly been doing over recent months. Speeches, spin and sound-bites really aren’t going to achieve anything beyond a bit of political point scoring.
The debacle over the huge pressures on A&E departments is a good case in point. The government’s own analysis shows that the causes are complex and are due how emergency activity is calculated, reductions in bed numbers, staff shortages in key hospital departments and the botched introduction if NHS 111, not a failure in out-of-hours primary care. Yet, the headline response – as trailed in selected newspapers on Tuesday – is to say it will all be ok if patients have named GPs.
Now, believe it or not, there is actually some sensible thinking going on in the Department of Health about how we can tackle the crisis in emergency departments – much of it influenced by doctors through bodies like the BMA. But it’s not headline grabbing – it’s focused on collaboration and better integration of the different emergency and out-of-hours services like doctors in Hertfordshire are doing with the NHS 111 service there. Herts Urgent Care provides both the GP out-of-hours service and NHS 111. In contrast to the situation in many other parts of England, the Herts NHS 111 service is operating well – one patient who used the service over the last bank holiday weekend described their experience as ‘gold standard’.
Despite all the evidence, Hunt continues to tweet that it is all the fault of the GP contract. This is because he does not want to bother with the facts when he can have a bash at those of us who, on his own admission, are over worked and strained beyond endurance.
The fact is GPs are undertaking more consultations per patient and we are diagnosing and treating more conditions that ever before. The fact is that GPs cannot become the providers of last resort for urgent out-of-hours services.
Mike Farrar, the chief executive of the NHS Confederation, also questions Hunt’s assertion that Labour was to blame for a public loss of confidence in alternatives to casualty by agreeing a new contract with family doctors in 2004. He said, “We do not see a correlation between the changes to the 2004 GP contract and the NHS 4-hour waiting standard for A&E departments.”
Hunt has continued to spout this rubbish when on Tuesday he told MPs that our contract had had “devastating impact” and that pressures on A&E services were “direct consequences of the disastrous changes”.
But Farrar said: “In fact, for the vast majority of the last decade, A&E waiting time standards have been improving. It is in recent years where the pressures have started to bite, and there have not been any discernible structural changes to out-of-hours GP contracts during that time.
“We believe real and lasting improvements to out-of-hours care are possible, but only if we put a greater level of investment in to primary, community and social care.”
If we don’t work together constructively to find a way forward, we’re quickly going to have doctors all over the country so desperately worried about their patients and their colleagues that they will follow the example of a group comprising almost all of the medical leads of emergency departments in the West Midlands who last week wrote an open letter to trust chief executives and clinical commissioning groups to say they could no longer guarantee safety in their units. GPs are not prepared to shore up a system that has been rendered unsafe by unwise political meddling. We are happy to work closely with others, including CCGs where there is full GP input, to improve out-of-hours services.
Though we are now seeing a flourishing of political short termism and sound-bite policy as we move towards the next general election, its roots have been well established by both the current and previous governments.
Six years ago, I was elected to the Chair of the GPC during very turbulent times that ended in the imposition of extended hours by a government that made my Mondays end at 10pm instead of 7pm. This Monday, as usual, I worked a 14-hour day – like many of you in this room. That government would not listen to reason and insisted that they had promised that GPs would work longer, so that was what we had to do, regardless of the impact or consequences. We said that the people intended to use the service would not benefit. Politicians did not listen.
Two years ago, we told the current government that the idea of NHS111 in England was all right but that they could not keep people out of hospital by doing it on the cheap with a call handler to nurse ratio of ten to one. The 111 pilots proved our point with hospital A&E departments seeing even more inappropriately referred patients brought in by ambulances that should have been helping the seriously ill. We said, “why don’t you have more trained nurses handling the calls in 111 and some GPs close behind?” Again, headline expediency won the day.
Now we have the dreadful spectacle of patients suffering due to a failure to implement NHS111 properly. West Birmingham, Greater Manchester, Solihull and Dudley are still struggling with NHS111, despite concerns being raised repeatedly by local GPs and LMCs. Staffordshire, Worcestershire, Warwickshire and Shropshire are now funnelling NHS111 calls through to their original out-of-hours providers. We warned the government that this would happen. They did not listen.
Six months ago, we were told major changes to our contract would be imposed upon us in England, which came into effect last month. This was despite what we thought were constructive negotiations up until that point with NHS Employers. Unlike the government, they seemed to recognise our description of GPs beyond saturation, unable to employ enough staff to deliver what patients need. A situation made worse more recently when the government ignored the Doctors and Dentists Review Body recommendations and gave us another, real-terms cut in income. While the administrations in Scotland, Wales and Northern Ireland reached agreement with the BMA, GPs in England are now trying to deal with a wave of new QOF targets, higher thresholds and extra work, in the new enhanced services, diverting valuable time away from treating patients and a fall in funding despite a further sharp increase in workload. We said this would happen. Politicians did not listen. Conference, do you see a pattern emerging here?
Mr Hunt’s predecessor famously said “that he wanted to take the politics and politicians out of the day to day management of the NHS” Now as you know, I’m not a fan of the NHS reforms in England – more on that later. But trying to limit the politicisation of the NHS and give local doctors more power to shape local health services was a vision we did share. Now, at the ripe old age of 54 days, clinical commissioning groups are already being instructed on what to do – not just by NHS England but by the Secretary of State for Health himself.
As well as being bad for the NHS and for patients, the political requirement for scapegoats is having a hugely negative impact on staff. A couple of months ago, it was the turn of the nurses. It feels like it’s regularly the turn of GPs. Of course there are a few colleagues who let us down and who make great newspaper copy, but the majority of us go many extra miles for our patients. We have to remember that our patients know that we continue to be by far the most trusted profession in Britain – more than nine in ten of the general public trust us compared with fewer than two in ten who trust politicians. But it really doesn’t help when we are working harder than ever before to see screaming headlines like “Time for GPs to work harder” and “GPs need to work harder – its an emergency!”
As I indicated at the start, we can expect even more turbulent times ahead – at least in England. While we must play our part in ensuring better continuity of care for our patients, we cannot – and will not – go back to GPs working dangerously long hours or having unrealistic expectations heaped upon us. We need to be freed from the oppression of box ticking and micromanagement. Let’s remember who made us tick more boxes and who reduced access for patients – Mr. Hand’s-off-the-NHS-I-leave-it-to-the-NHS Management Board. The Quality and Outcome Framework that we negotiated to support core high quality practice work should be used for exactly that, just as in the separate agreements reached this year in Scotland, Wales and Northern Ireland. It’s time to reduce the huge, unnecessary GP workload so we have time to treat patients holistically, to treat patients as people not diseases, and offer the continuity of care that we and they want and need. It’s time to give time to the patients who really need our care and attention, the vulnerable and the frail and the patients who the NHS currently fails.
The imposition, curiously is going to do what Conference wants with PMS and GMS by getting to the same financial position. Sort of and not as we envisaged. Actually, the two funding streams are not going to be bound together and the funding may not be shared and PMS budgets are not protected and we will not be able to help the serious losers who may go bankrupt and we will not be able to support practices at risk of closure and Conference’s opinion will not be sought. No modelling will be done either. So do not believe the misleading view from government that this is a GPC agreed element. We never agreed to this nonsense.
For the moment the four country contract stands as we are much more effective together than separately and negotiations in each nation feed off each other. This can only work if the common parts are the bulk of the GP contract and we must continue to fight to retain this for the benefit of our patients, who need the same from their GP, whether they are in Bedford or Belfast, Aberystwyth or Aberdeen
All that we can do on the contract imposition, we are doing. We have spent a lot of time producing a survival guide for practices, with details about the entire GMS contract imposition and the process of getting there on the BMA website available to all GPs, and held road-shows all over the country so that all GPs could hear from us how bad it might be. We will be monitoring the impact of the contract changes on practices and our patients to help us with further lobbying and to feed in to negotiations – such as they may be – for 2014. Just as importantly at this dangerous time, we are preparing new support material aimed at patients to help GPs explain service changes and pressures to them.
Recently, Robert Francis reported on the terrible events in Mid Staffs. If ever there was a situation that required a calm, constructive and collective response this is it. Again, no amount of political point scoring – by anyone – is going to prevent this happening again. While doctors are looking at what we must do, we have to be heard when we say the culture of the NHS in many organisations is corrosive. Though hard for the public and patients to believe, many doctors feel bullied into not speaking out when they see things happening that they do not feel are right. Thankfully, many still do. But it has to become the rule, not the exception. And through a genuine change in the culture, not by introducing new laws that will make things worse by creating more of a climate of fear.
This April finally saw the arrival of the latest top-down, NHS reorganisation in England. A version of a vision presented by government when it announced its plans sounded pretty good to many GPs – they promised more power to local clinicians and less political interference. But I’m really worried that an alternative vision is taking hold, where competition rules the roost and tenders are won by the lowest bidder with little regard to quality. Advocates of the reforms will say this is conjecture, conspiracy theory, shroud waving. But it’s already happening. How else can one explain the bizarre turn of events when all the GPs in Hackney tried to take back Out of Hours Care and were stopped by the PCT?
Clinical commissioning groups still have a chance to protect what is best about our NHS. But they must do this by working with all GPs in their area and with colleagues in their local hospitals and public health services, and with patients and the public. They are the only hope of a safety net – to ensure we do provide better integrated care and that, above all else, patients have access to high-quality, local NHS services.
However much we dislike what is happening, GPC has to help GPs cope with the new health environment in England, and we have issued plenty of material to help them avoid the pitfalls of this new system. We must not see the rise of conflicts of interest or competitive tendering that ends in repeated court battles. The BMA’s new patient resources will help explain the changes to a wider audience.
One of my biggest fears is for the next generation of GPs. With a shortfall in GPs applying for partnerships and areas such as Bradford and Hull where there are serious recruitment problems we desperately need more young doctors to choose this path. Yet the trainees’ supplement that enables trainees to afford to train in general practice has just been cut. We’re lobbying hard to protect this supplement, as well as to try to secure funding for the fourth year of training. We’re also supporting the Trainees Subcommittee as the junior doctors continue discussions with NHS Employers on proposed changes to their contract.
Another group who are particularly vulnerable currently are locum GPs. Locums are a vital part of the workforce and as we attempt to respond to new and rising demand, we need them more than ever. Yet, in just the last few months we have had a disastrous change in how locum superannuation is paid – reducing funding to those practices that use locums the most. These are likely to be some of the smallest practices and therefore the most vulnerable to staffing shortages. The most recent response from Health Minister Dan Poulter accepted many of our arguments on this issue but a subsequent letter from the Health Secretary seemed to reverse that position. We’ll continue to try to get a straight answer to a clear problem.
On the regulatory front, just when we thought we could not be more closely observed, we can now expect a new Chief Inspector of Primary Care. GPs are committed to providing high quality care to their patients and will work with the new regulatory framework to ensure that patients continue to have confidence in their local practice. But, as ever, the system needs to be practical, proportionate and supportive.
With revalidation and the CQC registration of general practice – both introduced in the past year – we have liaised closely with the organisations involved to make it work, for patients and doctors. But despite all this effort, there are some appraisers and inspectors who see their role as enforcers, out to rid the service of GPs who do not fit with their view of what GPs should be. How such people get into positions of power over others I do not know. The system might even work for principals but how locums can get feed back from patients when they are never in the same place for more than a day I do not know. The GMC says that locum appraisers can agree to look at things other than multi-source feedback. Some appraisers do not seem to know this. Now locum GPs will have to pay for their own appraisal, with no warning this was coming. To make matters worse, the money that was earmarked to pay for CQC work was in the organisation domain of QOF. So Treasury took it away. Is there no prospect of any good news for GPs? Probably not while no-one in power listens or cares about General Practice.
Having listed all the problems, it’s important to remind ourselves that we can work constructively with the Department of Health and NHS England to get the right outcomes for our patients that are also fair to us. Other matters tackled this year included the Premises Cost Directions that will, we hope, secure GP premises into the longer term. We have also introduced shingles vaccine for the elderly, flu vaccination for children, and an emergency arrangement for MMR catch up. All of this took a lot of effort and most of it achieved without the kind of difficulty we had with the GMS contract itself – mainly because the politics didn’t get in the way.
Looking further ahead, we need to plan for the next generation of GPs, whatever the world looks like. This means a real debate within the profession as well as an engagement with patients about what they really want. If society wants GPs available round the clock for routine matters, they will have to understand that daytime access will diminish or there will need to be a greatly expanded GP workforce.
Is the profession ready to deliver what society appears to demand? If not, what can we offer? GPs will have to wise up or shrivel. We may have to work in bigger partnerships, or federate through some kind of franchise system as some GPs have done. I think that economic pressure is going to make this happen and we would be wiser to lead the wave rather than follow it. Why do some patients want continuity with few GPs while others want a quick service whenever they access it? Is it just about the age of the patient and their co-morbidities? GPC and LMCs have to get on and find out. Our debates this week will get this going but we all need to recognise that the aspirations of younger GPs are different. They do not want to work in the same way as many of us have always done and we have to consider their futures too.
GPC is taking the lead on this and actively looking at various futures. Practices need central and local support. GPC is working on material centrally but we must do this together with LMCs and GPs if we are to bring light to the impending darkness.
Many GPs now choose to be sessional and should not be penalised for that choice. We need to protect them from unfair employment practices and ensure they are an integral part of the political process. This means that LMCs need to strive, as GPC must, to be inclusive of all GPs, whatever their contractual status. LMCs need more and younger colleagues to share the decision making so they can shape their future. We need to harness the talents of all, in the boardroom as well as the workplace. Debating, sharing, engaging, now.
So what of MY future? My future is to go back to my practice and try to stop the government from bankrupting it. On July 18th I step down after 16 years on the Neg Team. Some of you will breathe a sigh of relief, though not as much as my wife. I have been privileged to be elected to the task, and to have received the support of most of the 46,000 GPs.
I have many people to thank including the UK Negotiating Team of Richard, Peter, Chaand, and Dean, the three Celtic chairmen Alan, David and Tom; our genius assistant secretary and chief lay negotiator Fleur Nielsen, Chris Finlan and Gail Norcliffe our heads of division, all the Senior Policy Executives, Executive officers and admin staff of GPC, and of course our PA Jenny Jamieson without whom nothing moves. I also want to thank BMA staff including the Press and Parliamentary units, the Health Policy Unit, the Pensions Department and our lawyers. I must end with a word of gratitude to the GPC who elected me and who have supported this team of Negotiators through some rotten and many good times.
Thank you also to the Conference that elected me to GPC, and where I will return next year – my 29th attendance – as an ordinary member.
I want to end by celebrating the achievements that you – we – have made over the last decade. The very fact that we are talking about the consequences of an ageing population is, to a large part, because of the excellent care provided by GPs and our practice teams. An aging society is something to celebrate not something to be troubled by, and it’s time the government praised us for what we, and our contract, have delivered. And that’s something that stands well clear of the often-grubby world of politics.
Bye for now.