It’s a still summer’s morning in the heart of the capital, and Londonwide LMCs chief executive Dr Michelle Drage is dreaming of a brighter future for general practice.
‘Commissioning needs to be turned on its head,’ she begins, in a tone that is calm but insistent. ‘Instead of top-slicing monies to shunt into secondary care, the bigger budget needs to be top-sliced and primary care needs a secure amount.’
Think what you could do with a 20% share
‘An increase to 10% of the [NHS] budget would maintain just-about-OK general practice services. Think what you could do with a 20% share; think how much more you could spend supporting general practice to prevent admissions to A&E, prevent unnecessary or inappropriate referrals, increase consultations and support community services.’
It’s a compelling, if somewhat optimistic, vision. But it’s also one that addresses a pressing problem.
• Chief executive officer of Londonwide LMCs since 1993
• On the GPC since 1998
• A GPC negotiator from 2004 to 2008
• Honorary assistant at Richford Gate Medical Practice in west London
A Londonwide LMCs survey last month of more than 600 of the capital’s 6,000-odd GPs found their practices are stretched tighter than ever, with 83% describing their current workload as ‘unsustainable’. But as well as the usual suspects – increasing bureaucracy and decreasing funding – the survey singled out hospitals ‘dumping’ work on GPs as a major factor.
Some 59% of respondents said patients were being discharged from hospital with insufficient medication, and 90% said patients came to them within five days of discharge with ‘poor or no clinical information’. Practices reported spending an average of 10 hours a week chasing referrals and discharge details.
Such problems are not limited to London. LMCs across the country increasingly complain of unfunded work being offloaded onto general practice, with Cleveland LMC earlier this summer even publishing a weekly ‘work creep’ list, naming and shaming the worst offenders.
It is, Dr Drage admits, an ‘endemic’ problem. But it is one that is getting worse, as hospitals pile increasing pressure on their clinicians to work faster – and she is determined to find a solution.
‘All the tensions that were just about bearable before are now showing signs of major cracks,’ she says. ‘GPs and nurses are covering [hospitals’] tracks. And that involves additional workload to that which you really need to be doing for patients. It means more frequent consultations and less time for the people who actually need general practice, as opposed to people the hospitals are, in effect, discarding.’
No provider in any other industry would accept what GPs have tolerated in London
Dr Drage – a no-nonsense veteran of medical politics – says this is a prime example of the problems of an interconnected system at crisis point.
As head of the country’s largest LMC for the past 20 years, she has helped London’s 1,400 practices weather enormous change, and, aside from the big-picture strategy, is working through a laundry list of ‘operational issues’.
We meet in a small room within Londonwide LMCs’ headquarters, tucked away in one wing of BMA House. On a whiteboard in the corner, an almost indecipherable flow chart hints at the scale of Dr Drage’s challenge.
Top of her in-tray are the payment problems that have dogged practices across the country since NHS England and CCGs took over from PCTs in April. Dr Drage estimates ‘95% to 100%’ of practices have been caught up in the resultant chaos and puts it candidly: ‘No provider in any other industry would accept what GPs have tolerated in London.’
Then there are difficulties with the recruitment of GPs and practice staff, as well as new issues such as local authorities’ insistence that GPs wrestle with ‘300-page’ tender documents in order to bid for public health work.
‘There’s no specificity, no recognition that actually we’re just dealing with small organisations,’ she says. ‘However big you are as a practice, you’re still relatively small compared to Serco.’
But while Dr Drage’s focus is the capital, she also has one eye on the national picture. Having served as a GPC negotiator from 2004 to 2008, she stood for election as GPC chair this year as part of an eye-catching joint ticket with Birmingham GP Dr Fay Wilson.
In the 21st century, the tactics of the 1970s are tired
She was, she admits with a rueful smile, ‘gutted’ to lose out to Dr Chaand Nagpaul, whom she praises as a ‘good friend and a good local GP’. There was some satisfaction though in laying down a marker for other female GPs, particularly in a year when male domination of the negotiating team has come in for criticism.
‘We enabled people to see that we can, as two women, stand both as women and as a job-share. We raised the profile of women in the GPC, and more women were elected across the board; at the LMCs conference, at the ARM and obviously Beth [McCarron-Nash] got back onto the negotiating team. To that end I think we were very satisfied.’
Dr Drage hopes Dr Nagpaul’s election will herald a change from the negotiating strategy of his predecessor, Dr Laurence Buckman, and a greater willingness to engage with the Government.
‘I think in the 21st century, the tactics of the 1970s are tired,’ she says bluntly.
And what of the most pressing issue facing GPs – Jeremy Hunt’s threat to hand out-of-hours responsibility back to the profession? Dr Drage is sanguine about what she describes as ‘sabre-rattling’ from the health secretary, and suggests it’s unlikely to happen: ‘He can’t afford to have battles with general practice in a run-up to an election.’
She believes the agenda has ‘moved on’ from out-of-hours, and is positive about NHS England’s latest consultation on the future of general practice, insisting much of it ‘plays to our tune’.
‘We should be locking into that and engaging in it where we can, showing them that the way we manage out-of-hours demand is by doing what they think they’re going to – strengthening general practice.’
Once again, Dr Drage is thinking of a bright future for general practice. GPs will hope her vision comes to fruition.