Conference of Local Medical Committees 2005
Speech by Dr Hamish Meldrum, chairman of the BMA's General Practitioners Committee
16 June 2005
"Good morning conference.
First of all I’d like to thank all of those who have helped me in this, the first year of my chairmanship of the GPC. It’s not only the greatest privilege to represent and lead the profession I love, it’s also a huge privilege to work with, and be supported by, such a fantastic team of people, both doctors and non-doctors, and I thank them all from the bottom of my heart.
My first year has coincided with the first year of full implementation of the new GMS contract. No doubt there will be some who will say that we’ve both had our good and bad moments! Certainly, in terms of the new contract, we’ve not had to go looking for problems. You only need to scan through the list of motions for debate over the next two days to see what some of the issues have been – enhanced services, superannuation, premises and general funding issues relating to the global sum and PCO-administered funds.
However, on the positive side, I believe that the quality and outcomes framework has been hugely successful. I want to put on record my congratulations to the practice teams the length and breadth of the four countries who have risen so wonderfully to the challenge. They have demonstrated that if you give general practice the resources, it will deliver. They have shown what we have been saying for years – that the quality of UK general practice is second to none. You have been rightly rewarded for the massive contribution to the health of our patients.
Given this, it is a disgrace that some PCTs have been making crude and arbitrary distinctions between practices as a consequence of their relative performances in the QOF. A PCT in the midlands is a case in point and its name and shame attitude, hectoring tone and implied threats in respect of several of their practices is completely unacceptable. Well, naming and shaming can work both ways and I believe that the Heart of Birmingham PCT’s behaviour cannot and should not be tolerated.
There are also those who claim that GPs have been too successful, that the QOF was “too easy”. Rubbish! Practices have worked extremely hard to achieve such brilliant results. What would they rather have had us do? Only give high-quality care to 75% of our patients? Only take on a few of the domains of the QOF so that we could keep to the budget forecasts? Then we would have quite rightly had to face the accusations that we were not delivering a quality service to our patients. We must build on the success of the QOF and what I believe to be the highly cost-effective move towards helping, at long last, to provide a genuine HEALTH service rather than just an ILLNESS service.
Today, however, I want us to look forward and not back. I also want to address a wider audience than just yourselves or only GPs. We are the representatives of general practice and, of course, must ensure that we speak out for and support those we represent. But, I would argue, to represent our colleagues fully and effectively, we must be involved with issues that are much wider than just those that can often be viewed as serving a rather narrow, sectional self-interest. There is no point in having a worthwhile point of view if you’re not in a position to promote it to the widest possible audience. As negotiators, we’ve often been criticised for not shouting loud enough or not banging the table hard enough as part of the negotiating process. That’s all very well, but it’s a pretty pointless behaviour if you’ve not even been allowed into the negotiating room in the first place!
That’s not to say we are not going to give the problems I mentioned earlier and the review of various aspects of the contract our greatest attention but we mustn't forget that the contract is not an end in itself. It is primarily a vehicle for paying us – and, of course, I realise that that has just a smidgen of importance for all of you!
I’m conscious that when I start to talk about some of the wider issues affecting general practice, there may be those who will argue that I’m responding to a particularly English agenda. At the moment, that may be partially true, but I counsel my Celtic cousins not to be complacent and believe that what is happening in England today will not affect Scotland, Wales and Northern Ireland tomorrow. Only two weeks ago I spoke to GP colleagues from all over Europe and it is clear that it is not just in the UK that the challenges of changing professional aspirations, the impact of a greater number of providers of primary care, the apparent desire to downgrade the importance and influence of doctors and the infatuation with private sector involvement in the health service are all having their effects.
I know it’s stating the blindingly obvious but we must never forget that the NHS is firstly and lastly about patients. However, fortunately, it’s also true that much of the time, what’s good for patients is also good for doctors. Moreover, patients trust us. All the surveys show doctors at the top of the table when it comes to trust, with politicians at the bottom. Quite where that leaves a medical politician like me, I’ll leave others to judge! But trust, like respect – another buzzword of the moment – is not something we can take for granted. It has to be earned.
The changes to out of hours, to more part-time working, to increasing diversity in the workforce are all changes which have the potential to damage that trust and we will have to work harder to ensure that we maintain and strengthen it. So, I say again, patients do trust us. They trust us when we discuss treatment options with them and advise them on the best choice. I believe they also trust us when we speak out for them and the wider NHS.
So why don’t politicians trust us? They seem to trust individual doctors who they turn to, from time to time, for advice. Why don’t they trust us, the representatives of all doctors? Could it be that they only trust those that they believe will tell them what they want to hear rather than those who will tell them what they need to hear?
Shortly after she was appointed, Patricia Hewitt in announcing the White Paper review of family health services said that she wanted to listen and learn and to hear the views of people working in the NHS. I met Patricia Hewitt last week and she reassured me of these intentions. So, today, I want to make public the offer I made to her and the new government health team. Involve us; listen to us; trust us. You will not find us wanting. I will not criticise you for not always acting upon what we say, but I will criticise you for not involving us or listening to what we have to say.
In making that offer don’t misunderstand me. I said in my election statement last year that my natural instinct is to be principled and courteous in the way I do business; to encourage, argue and persuade where I can – and I stand by that - but I also said that no-one should be in any doubt about my determination, my resolve and, where necessary, my sheer bloody-mindedness to get the best for the profession I love.
In recent weeks, I and the rest of the negotiating team have been visiting LMCs. It’s part of my resolve to try to improve the communications and strengthen the links between us. Can I take this opportunity to thank you all for both the hospitality you’ve shown us and the courtesy and friendliness with which we’ve been received. I cannot overstate how important it is that we build on and develop the two-way dialogue between us. Shifting the Balance of Power has demonstrated why we need to be at our professional best both nationally and locally and I welcome any ideas as to how we can continue to help each other to carry out our representative roles even better.
During our visits, one of the commonest complaints that we heard is that the profession and indeed, the wider NHS, is suffering from change, or as I like to call it, implementation, fatigue. I often wish the government would start suffering from initiative fatigue! It wouldn’t be so bad if all the initiatives seemed to have a coherent purpose, but more often than not, they appear to work at cross purposes. Many of them certainly make me cross!
One area where there does seem to be some consistency of purpose is in the government’s headlong rush to create more private sector provision of NHS care. I don’t believe we should oppose private sector involvement, per se, but before we go too far down that road let’s just ask a few questions. What are the problems to which private sector provision is the answer? Will it really improve capacity in the NHS? Will it make the NHS more efficient? Will it solve the workforce problems in the NHS? Is it value for money? Will it provide better services for patients? Where is the evidence? Even more particularly, where is the evidence that it will improve rather than destabilise our present system of general practice.
Proponents of private sector provision state that it will do several things. They say it will innovate, create diversity, be more flexible and adaptable, be more efficient.
Let’s look at these claims in turn and compare them with what we can provide in general practice.
Innovation. British general practice has been one of the most innovative and forward thinking parts of the NHS. Take computing. Why is it that GP computing is light years ahead of the rest of the NHS? It’s because GP computer systems were developed for GPs, by GPs, by people who worked at the sharp end of the service and knew what the service needed.
Diversity. Here again, British general practice is incredibly diverse, with a multiplicity of contractual options; practices ranging from the single-handed to the large, multi-doctor practices or even multi-practice consortia; from inner-city to rural; from prescribing to dispensing. I rest my case.
Flexibility and adaptability. Given the number and the rate of changes that we’ve seen over the last few years I believe that British general practice has more than demonstrated its ability to be flexible and adapt. I’ve already highlighted the latest glowing example of that, the outstanding success in the delivery of the QOF.
Efficient. Given that we carry out almost nine-tenths of the consultations in the NHS for just over one-tenth of the resources, that we do this with fewer doctors per head of population than many of our western neighbours, I don’t believe that we’re the ones who need to demonstrate our efficiency compared to other methods of primary care delivery.
Given all that, I don’t think we should necessarily be afraid of the principle of private sector involvement. I have confidence in the ability of UK general practice to compete. But there is one big proviso. We must be allowed to compete on a level playing field and not with one or both hands tied behind our back. The initial, less than subtle hints emanating from the Department are not auspicious. So we have to ask, if private sector provision is so wonderful, so efficient, so effective, why does it have to be given such a significant financial leg up?
I’ve criticised governments for the confusion and incoherence of many of their policies and offered to be helpful – genuinely helpful! In meeting these challenges we need to be consistent in the way we respond. There is a very understandable tendency always to be negative in the face of imposed policies but I want us to try, where possible, to avoid knee-jerk negativity. We also need to be better at developing our own policies rather than just being reactive to the policies of others.
Developing policies in a rapidly changing environment can be difficult and we have to really focus on the principles that underpin our system of general practice rather than just the mechanisms by which we deliver it. We also have to judge the policies of others by how much they conform to or work against, these principles. The principle of whole-patient, list-based primary care, where every individual has their own local surgery where they are known and can get personal care and where no-one is simply motivated by profit, the principle of promoting fairness and equity, the principle of a comprehensive, free-at-the-point-of-use health service, the principle of patient advocacy and of patient confidentiality.
We have to continually remind governments that we are the only true generalists left in the health service, that we are the diagnosticians, that we are the ones who can live with uncertainty, that we are the experts in dealing with the increasing incidence of long-standing conditions and co-morbidity and that we are the ones who successfully guide patients through an increasingly complex and diverse health service.
Of course, we must - and we do - work with others but this must be in the context of respecting each others’ strengths and weaknesses and not pretending that everyone can do everyone else’s job or, as some in government seem to want to believe, everyone else can do the GPs’ job.
The theme for our conference is “Speaking out for General Practice”. I am sure that we will speak out in a loud and clear voice about the problems still facing general practice; speak out about the fact that there are still too few GPs, speak out about the problems that remain with the contract, speak out about the under-funding of GP trainers and training, speak out about the persecution of small practices and speak out about the failure to sort out community hospitals.
But I also want us to speak out positively about the strengths and principles of UK general practice and the ongoing commitment of its GPs.
So, when the new Secretary of State consults for her promised white paper on family medicine she should come to the people at the heart of it: the patients, of course, and us, their trusted, innovative, cost-effective, valuable family doctors.
And we will tell her. We can deliver. We do deliver, and we will continue to deliver a family health service that is fit for the future.
Thank you".