Thank you colleagues!
This is the third and final time that I will stand here and address you as the Chair of the Royal College of General Practitioners. In both of my previous speeches, I’ve used a story or metaphor to illustrate the value of general practice and medical generalism. To point out the pressures we are under and how essential our service is – in and of itself AND to the wider NHS.
My first speech compared general practice to the wall of a dam, under huge pressure from rising waters and with downstream services protected by the dam wall, but in grave danger of being overwhelmed should the wall give in to the pressure and burst. Last year, in Glasgow, I spoke about my own family’s experience of illness and premature death and how the world has changed such that managing multimorbidity – with all that means for medical generalists – is perhaps the greatest challenge for the NHS in the 21st century. And I also spoke about how we need to collaborate and work with each other.
In this, my final speech to you, I want to consider leadership, what that has meant for me and what it means to you. And I also want to reflect a little on the themes of the previous years. When thinking about leadership, it is common to look at history and literature for case studies of the lives of great leaders.
A number of courses and programmes use such examples to illustrate leadership skills. One text commonly used for this is Shakespeare’s Henry V. Many of you will know the play, or be familiar with the story, but in terms of a leadership journey it goes something like this. Henry has a vision – for England to reconquer lands in France. He is highly effective in communicating this vision to his nobles and his troops. He has to deal with doubters – in this analogy they are traitors and are promptly executed. Not a leadership strategy I personally recommend!
On the eve of battle, he undergoes what is often described as a long dark night of the soul. What am I doing? I am leading my loyal soldiers to slaughter, my name will live in infamy. He then inspires his team – ‘we happy few, we band of brothers’; demonstrates the superiority of his strategy and wins the battle of Agincourt, against overwhelming odds. Now it is notable that Henry V is usually chosen for these exercises as opposed to other, more infamous Shakespearean leaders such as Macbeth.
Yet when you look closer at the two characters’ leadership journeys, there are common themes. Macbeth has a vision, albeit communicated by three witches, to become King of Scotland. He communicates his vision to Lady Macbeth. He deals with the person standing in his way – that is to say he stabs the good King Duncan in his sleep. He – and Lady Macbeth – then spend the rest of the play in their ownlong dark night of the soul, becoming lost in regret and madness. I can’t see much evidence of teamwork but he did become King and the witches’ vision – or prophecy – was fulfilled.
So what is the difference between Henry V and Macbeth? I’d suggest that it comes down to leading based on the right vision, and the skills and determination to translate it into reality.
If literature and Shakespeare are not your thing, we can think about the lessons from one of my favourite movies, Star Wars. Look at the leadership journeys of Darth Vader and Luke Skywalker. Obviously there are clear similarities with Henry V and Macbeth.But how about Princess Leia or Han Solo (my personal favourite) – both of whom lead and achieve, without being able to draw upon those very nifty Jedi powers. Everyone has a leadership role to play and a journey to go on in their own way.
So how does this translate to the leadership journey within a general practice context? To what end do we take this journey? What will we as GP leaders in practices, in local health economies, at regional, national or international level achieve? What is our vision for leadership? How we react when the obstacles in our way seem insurmountable? And do we end up with Agincourt or Dunsinane, the Death Star or galactic liberty?
It would be tempting at this point to talk at length about my own leadership journey over the past three years and what your College has achieved in terms of our ‘Put patients first: Back general practice’ campaign.
And make no mistake, I am immensely proud of the way in which the College has run this campaign and the way in which you as members have worked to get its message across. Together we have made the crisis in general practice a national talking point, in the media, in all four national legislatures, and amongst the public, three hundred and thirty thousand of whom signed our petition calling for more investment in general practice.
And together we have made a difference. In Scotland, Wales and Northern Ireland, we have secured additional funding for primary care and a new drive to tackle GP workforce shortages. And in England, we have secured the GP Forward View, with its historic pledge to increase spending on general practice by at least £2.4billion per year by 2020, and to increase the number of GPs by 5000.
But I feel strongly that this speech – that this conference – should be about the future, and your own leadership journeys to come, for the betterment of general practice.
Last week, we issued a story challenging the denigration of general practice in medical schools and, indeed, the wider NHS. Two years ago when we were in Liverpool, I made a comment in one of our conference sessions about the toxic culture in medical schools against general practice. Simon Wessely, President of the Royal College of Psychiatrists and I have written in the latest edition of the British Journal of General Practice, warning that the systematic denigration of our disciplinesin medical schools is risking patient safety, and stripping patients of their dignity.
Our editorial draws on research that shows general practice and psychiatry are the two most ‘bad mouthed’ specialties within medical schools, and highlights evidence that this has a tangible impact on medical students’ choice of specialty. We speak out against a hierarchy that has been created in medical schools that ‘puts physical health over mental health, hospital care over community care, specialism over generalism and ‘medical’ specialties over ‘non-medical’ ones.’
And we call for this hierarchy to be replaced by ‘respect and understanding throughout medicine that all specialties are important, that all specialties have their own set of skills and values and the NHS will only function properly when we have sufficient numbers doctors practising all specialties.’
NHS England has recognised the importance of our profession. Its Chief Executive Simon Stevens has even said that ‘there is arguably no more important job in modern Britain than that of the family doctor’. Our patients value our service as well, with 92% reporting trust and confidence in the last GP they saw according to the latest GP Patient Survey.
Health Education England have recognised it too and are striving to achieve the Government’s target to increase the number of GPs in England by 5,000. But this will not be possible when forces from within are working against our efforts.
The denigration of general practice has to stop. The College is doing what we can to challenge misplaced and archaic stereotypes, and our Think GP campaign, aims to show what a fantastic career choice general practice can be. But it’s clear that more needs to be done from within medical schools, and medicine as a whole.
This is an area where we, collectively, can show leadership. We need to tackle this culture and not condone it. We need to stand up for ourselves, our colleagues, our students and our patients. I have spoken to students who say they are told general practice ‘isn’t medical’ or ‘isn’t intellectually stimulating’.
A GP might see, or deal with, 60 patients in a day, all presenting different conditions of differing complexity and severity – yet identifying and treating such a multitude of conditions isn’t deemed by some as ‘intellectually stimulating’ or ‘medical’!
Here at the College we will be launching our own student led campaign to change perceptions of general practice amongst medical schools. In a few days’ time students will be discussing this issue in this very venue, and I am looking forward to seeing what they can achieve when they take the lead in dealing with this endemic problem.
As well as GP Societies and our trainees, it’s a leadership challenge for all of us, to stand up to the denigration of our profession. This is not just a matter of taking pride in the important job we do, it is about securing a future GP workforce. If students are put off becoming GPs this will only worsen the crisis we already face in general practice. Our growing patient population needs general practice. Our overstretched secondary care sector needs general practice.
Our NHS needs general practice. And general practice needs new GPs, every year, to address the current shortfall. This is a key leadership challenge for our profession because if we don’t produce enough GPs then, returning to my original analogy of the dam, we don’t repair and strengthen the wall of the dam. The consequence will be that general practice will implode and the NHS will be overwhelmed.
Now I know that there will be some within the profession who doubt whether the dam really will be strengthened. The promises in the GP Forward View may be there, but right now the pressures that general practice is under are so great that it can be hard to believe that the vision of well funded general practice at the centre stage of the NHS is achievable and not simply a pipe dream. And it’s important that we do not shy away from recognising just how tough things are at the moment, and the length of the journeythat still lies ahead of us.
I believe that things can be different – that together we can turn the tide so that in future we have many more GPs staying on in the workforce for longer, with general practice recognized as the fulfilling place to work that it ought to be. Of course there will be setbacks, but when these occur, it is important that we do not go into retreat, but overcome them and hold fast to our vision.
The College has a central role in doing this by tracking the funding going into general practice and the realities of what is it like to be a GP. Being able to demonstrate the fall in investment over the past decade was a powerful factor in securing the pledges in the GP Forward View and other announcements in Scotland, Wales and Northern Ireland.
But it’s not just at the national level that the leadership challenge for general practice is being played out. Increasingly, we are seeing many of the most crucial decisions being taken at regional and local level.
Today, here at our conference, Helene Irvine, Public Health consultant in Glasgow and Clyde, will be sharing startling research illustrating how the failure to invest sufficiently in general practice has led directly to pressures in the acute sector at local level.
The College has supported the formation of the STPs as a critically important new initiative in the NHS that can function as regional engine rooms for a more collaborative approach to shaping services and dealing with challenges, such as the huge increase in multiple long-term conditions within the patient population nationwide.
The STPs will play a crucial role in shaping the future development of the NHS over the next five years. However, strengthening general practice should be at the heart of what they are about.
But in many areas our RCGP local representatives are struggling against an agenda that is focused on plugging ever increasing hospital deficits. This is a false vision, which, like that of the witches in Macbeth, may seem to offer short term gain, but will ultimately plunge the NHS into a vicious downwards spiral, resulting in disintegration and disaster.
Let us not allow this to happen on our watch. The general practice perspective must be fed in to any ‘health system’ transformation. Let us galvanise our colleagues, our patients and our communities to stand up for general practice in our localities, so that it can remain the foundation stone of the NHS. Let us lead the development of multi-disciplinary teams, so that we can deliver better care to patients with complex and multiple conditions, and create an NHS fit for the 21st century.
Let us lead the development of new forms of organisation that can improve the range of services we can offer to practices, from Federations – first championed by this College – to multi speciality community providers. And let us continue to assert the case for more investment into general practice.
Based on the limited information about STPs that has been published, very few contain specific pledges to earmark extra funding for general practice. Some barely acknowledge general practice at all. If STPs fail to deliver the funding for general practice – from the Sustainability and Transformation Fund – then the family doctor service stands to lose up to £760m in 2020/21.
So, I call on Simon Stevens to require all STPs to publish their financial plans, and to make crystal clear that unless they commit to invest more in general practice, their plans will be rejected and responsibility for the Fund regionally will be withheld from the non-compliant STPs. There is a need for strong leadership from Clinical Commissioning Groups too.
The College’s latest analysis of local commissioning spend by CCGs reveals that, by the end of 2016/17, they are on course to underspend by more than £33 million in general practice. This is not loose change down the back of a sofa. It is double what NHS England plan to spend on resilience teams this year and is the same as the amount that is due to be spent on tackling the problem of indemnity. It is real money that could make a real difference. The failure to spend money earmarked for general practice on general practice is a national disgrace.
And it is high time that CCGs realised that general practice is a vital component of the local healthcare system – not a fringe activity that can be used as a way trimming the fat from their budgets! We’ll be contacting CCGs straight after conference to tell them to utilise their budgets as they are meant to be used – to provide better support to local GPs, and practices.
Meanwhile, the perfect storm of declining investment, a static workforce, and increasing demand is still threatening. We may have won the battle on the GP Forward View but we must not be complacent about making sure that every last pledge is delivered. And under the leadership of our Devolved Council Chairs, we must redouble our efforts to win a comprehensive set of commitments in Scotland, Wales and Northern Ireland too.
We must hold fast to our vision and never give it up.
The last three years have not been easy as the Chair of the College. But, then it has not been easy to be a frontline GP either. And I’ve been both. However, I do believe that there are better times ahead. Looking back on my time in post, I am pleased to say that the narrative around general practice is changing, and I am proud to have led that change. Politicians and civil servants across the UK now seem to have got it:
- That general practice is the cornerstone of the NHS.
- That there is no more important job in modern Britain than that of the family doctor.
- That if general practice fails the whole NHS fails.
We now need to build on what we have achieved so far and move into a new era for general practice. I know you will be in safe hands as you work together to achieve this under the leadership of my successor Helen Stokes-Lampard.
Helen, let me tell you now, there is no greater privilege than being Chair of the RCGP. And it doesn’t half pay to have a working knowledge of Henry V!
I wish Helen and you all the very best for the future. At this stage, I am sorely tempted to say ‘May the force be with you’, but I think I will settle for good luck, goodbye and thank you!
