Highlights from the conference for local medical committees in England on Friday 10 November.
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Saving general practice
With an insufficient workforce, a funding plan that is no longer sustainable, a growth in population and a sea-change in the level of complex cases being presented, urgent steps need to be taken to save general practice.
GPC UK chair Richard Vautrey's speech delivered to LMCs
Right from the start I want to thank my executive team, Mark my deputy, Farah and Krishna. They’ve been in post for less than 3 months and have not just hit the ground running, but they’ve been sprinting from the start with the work they’ve had to contend with.
Thanks too to the team of dedicated policy leads, the wonderful sessional GP and GP trainees subcommittees and the many BMA staff members who work with us and on whose expertise we rely. Thank you to all of you.
I also want to pay tribute to my predecessor Chaand Nagpaul. We were both members of the negotiating team working with Laurence Buckman and then I acted as Chaand’s deputy for four years. Throughout that time I saw his passion for general practice and his commitment to make things better for GPs. He’s worked hard on our behalf and whilst I know he will continue to do so in his new role as BMA council chair, it’s right that we say thank you for all that he has done during his time leading GPC.
During the time that we worked together we often heard the question, “what has GPC ever done for us?” Well I’ll tell you what we’ve done. We’ve started to put right the problems of the last decade.
We’ve reversed much of an imposed contract, we scrapped the worst elements of QOF, we ended a whole series of micromanaging and bureaucratic DESs, not least the avoiding unplanned admissions DES which was the worst of the lot, we’ve secured non-discretionary maternity pay and guaranteed sickness pay, secured funding to cover in-year indemnity rises and we’ve even got full reimbursement of CQC fees.
And crucially, on top of all that, we’ve started to turn the tide on a decade of funding cuts and secured over £500m recurrent investment in to general practice in the last two years, investment that is vital for practices right across the country. That’s what GPC has done for you and all the GPs we represent and that’s what I’m proud to have achieved.
But I know it is nowhere near enough. Eleven years ago, in 2006, discounting the inclusion of dispensed drugs, the NHS spent 9.6% of its budget on general practice. By 2013 it had fallen to a miserly 7.4%. And even now, when we are at long last seeing a rise in both the amount and the proportion of investment being made, there is still a massive gap of £2bn to get us back to 2006 levels in real terms. By 2021, when the GP Forward View investment has been completed, there will still be a £3.4bn gap to hit the not unreasonable target of 11% NHS funding spent in general practice.
Out of £120bn spent on the NHS is 11% too much to ask for? With rising consultation rates, increased work shifting from hospitals in to the community, with the population rapidly increasing, with our patients living longer, and living with more complex problems and who not unreasonably need to see their GP more often, with all of that, is 11% too much to ask for to sustain the best and most comprehensive general practice service in the world?
£142.63 per patient, that’s all a typical non-dispensing GMS practice gets for a year’s worth of unlimited care. That’s 57p a day; 57p a day. That’s all this and previous government’s seem to think patients are worth, all that they think general practice is worth, and so is it any wonder practices up and down the country are struggling to keep the show on the road.
We should not be left trying desperately to deliver a complex and specialised service with so little. We are GPs, leading skilled multidisciplinary teams in and around our practices. We are highly trained generalists who are specialists in delivering holistic care that makes a difference to all aspects of our patients’ lives and we need the resources necessary to do that.
We are professionals delivering the most popular public service not just by coincidence, but because of our hard work and dedication, our willingness to innovate, our ability to respond rapidly to change and because we know our patients and we are willing to stand up and fight for their healthcare.
Is 11% too much to ask for? For a comprehensive, responsive, sustainable, free at the point of access service, of course it isn’t. And, unlike some services that NHS England seems to support, we don’t cherry-pick young, fit and healthy patients. We don’t refuse to treat people who are vulnerable, frail or housebound, those with learning disabilities or complex problems. We deliver a service that is open to all, no questions asked.
If we really are to see the vision of care closer to home realised, with far more of a patient’s care being delivered by teams working in their communities, then we need politicians and policy makers to start putting their money where their mouth is, to back the rhetoric with funding decisions that will make the difference to our patients lives and help us to deliver a service we know can be achieved.
But it’s not just about percentages of investment. The overall budget for the NHS is simply too small. As a nation we still lag a long way behind comparable countries in the EU when it comes to how much of our GDP we spend on healthcare. This is a political decision, and at the moment our politicians are failing to make the right call.
They can and should be making the decision to invest more in the NHS as a whole. They can and should be prioritising not just general practice but our community services, our mental health services, our hospital services, our social care services, all of which are under huge and growing pressures. Our NHS is sick and needs urgent treatment.
The response of the NHS has been the capped expenditure programme. CCGs around the country are being forced to make swinging cuts to balance the books. Growing numbers are unfairly discriminating against groups of people and making them wait longer in pain before they can get the operations they need. They are trying to pretend rationing access to treatment is a health promotion measure. This is wrong, and CCGs and policy makers should be far more open and honest about why these cuts are being made.
And despite the promises to preferentially invest in general practice, it is yet again primary care budgets that are facing the chop with some CCGs considering cutting enhanced services and others not even being able to spend the promised £1.50 per patient transformation funding.
The reality therefore is CEP is not just yet another bit of NHS management speak; it’s not just another three letters plucked out of the scrabble bag with the hope of making a policy out of them; the reality for general practice is CEP stands for Cuts to Essential Primary care and it’s simply not acceptable.
If we are to avoid a crisis this winter like never before, if we are going to be prepared for a flu outbreak that could stretch our already fragile services to breaking point, if we are to avoid more patients struggling to get the care that they need, then we need not just urgent investment, not just another short term fix, but we need a long term commitment to fund our NHS and social care services to a far greater level, and to a level that our patients expect.
But we also need to value our dedicated and hardworking staff far more. The 1% pay cap imposed following the international financial crisis and a government policy of austerity has unfairly taken advantage of the goodwill and selfless vocation of NHS workers. For GPs the thought of even a 1% pay increase has been a distant dream over the last decade, with cuts in real terms pay year after year after year since 2006. This pay cap policy has undermined recruitment and left a demoralised and undervalued workforce. It’s a policy that must end.
I call on the Chancellor, at the budget in a few days’ time, to scrap the cap, and provide the funding needed to not only pay GPs, our staff and others in the NHS properly, but also to invest in NHS services as a whole. Our staff and our patients deserve nothing less.
To meet the growing needs of our patients and to deal with the dangerous workload pressures facing GPs and our staff, we need recurrent funding to enable an expansion of the workforce. To his credit, the Secretary of State remains committed to securing an additional 5000 GPs, despite the massive challenges of achieving that goal.
Following pressure from GPC we’ve seen improvements to the induction and returner scheme, and to the GP retainer scheme; we welcome the increase in medical school places with a greater emphasis on recruiting GPs for the future and we’re pleased to see the significant expansion of the international GP recruitment programme. But unless we also secure recurrent funding we won’t be any better off.
We also welcome the promises of more nurses, both in our practices and working alongside us in our community teams, more pharmacists, an expansion of the number of mental health therapists, greater access to physio first schemes and more admin support to take away some of the unnecessary tasks that many GPs find themselves doing. But unless we also secure recurrent funding we won’t be any better off.
Far too many of us desperately need radical improvements to our practice premises. Too many of us are working in buildings that should have been condemned in the 19th century let alone be suitable for quality health care delivery in the 21st. For many practices the rate limiting factor to their ability to do more for their patients is insufficient space in their premises. But despite the promises of £1bn capital investment, the estates and technology transformation fund has singularly failed to deliver. But worse, CCGs claim to have no funding to support increased rent reimbursements. And so yet again, unless we also secure recurrent funding we won’t be any better off.
Is it any wonder that so many practices have reached breaking point? Is it any wonder that so many trainees are looking at the risks of partnership and deciding it’s just too risky and the workload too great so they are choosing salaried or increasingly locum roles instead?
And is it any wonder that 54% of practices responding to our survey said that they would be willing to temporarily suspend patient registration and 44% said they’d be prepared to close their list altogether in order to keep their patients safe and to keep themselves sane.
Practices are closing their lists not just to make a point, but because they care for their patients. They close their lists as a last step because they want to be able to provide a safe service and do not want to put either their patients or themselves at risk. So, we stand by our colleagues in Folkestone and elsewhere who try to protect their patients in this way, and shame on those CCGs that do not support practices in crisis situations. CCGs should be finding solutions to the crisis practices face, not making the situation worse.
It just takes a doctor to retire and another to go off sick for a stable practice to become unstable. Too many of our practices are carrying vacancies because they cannot recruit. It not only puts patients at risk but it leads to GP and staff burnout as they do their best to cope. This is why we need to do more to protect and support one another.
The roll out across the country of the GP Health Service, which we pushed for, has already provided valuable support for over 840 GPs and trainees who are suffering from stress, depression or addictions, mental health problems that have often been caused by the workload pressures they are under. The GP resilience programme has also now provided support for over a thousand practices that were right on the edge, bringing help that is some cases has made it possible for them to carry on and improve what they do.
We’ve also led on important work to both reduce the workload burden on practices and help patients to get the right care in the right place through changes to the hospital contract, providing tools to say no to unacceptable and unfunded workload shift from secondary care and working with patients’ groups to develop information for patients on what they should expect when a referral is made. Now we need CCGs to up their game to ensure hospitals are held to account in delivering these changes.
LMCs are good at protecting and supporting practices and GPs in their area. Its part and parcel of what you do, day by day, week by week. But when the systems that are meant to support LMCs fail it makes your work so much harder. The repeated and multiple failures over the last two years of Capita’s Primary Care Support England service have not only made your lives difficult, but they’ve also created major problems for practices and led to anxiety and misery for countless GPs.
And then just last week we saw front page headlines of a GP trainee who was left without pay for two months, so that her trainers had to step in with a loan and the Cameron Fund was needed to give her emergency funds so she could buy a present for her daughter’s seventh birthday. How can a service that does that say that it supports primary care?
If a practice had failed so badly and so often it would have been closed down by now. It really is time NHS England got their act together and sort out the mess that they created when they ignored our advice and tried to cut costs by privatising this essential service on which all practices depend.
Getting better about protecting and supporting one another is also why GPC is committed to developing an alarm system to alert the local area that the practice has reached capacity and needs help. We know this raises complex issues but we need pressure-valve options that can be triggered at times of crisis and enables practices to focus on providing safe levels of care to their patients.
We can, and should, take greater control over our own destiny. Our independent contractor status gives us the ability to do this, and is one amongst many reasons why we give that up at our peril.
At a time of crisis it is easy to be persuaded that the grass is greener elsewhere. When you’ve suffered a decade of underfunding, when you can’t recruit and are left with unsustainable workload, or when your premises feels like a noose round your neck, the temptation to exchange your national GMS contract for a local ACO/MCP one may well be tempting.
But this is not fundholding or PMS, where the first wave did better than those that followed. Such schemes come and go but each time those practices retained the solid foundation of their national contract or had certainty they could return.
This time it should be seen as a one way street. As our guidance document makes clear, once in it will be very difficult to get out and restart your GMS practice. For some who have reached crisis point it may be the right decision for them, but that’s not the case for the vast majority of us.
Yes we should be collaborating more with those around us; yes we should be building and leading teams within our localities, rebuilding those community primary healthcare teams we once had but were taken away from us; yes we should be developing systems that bring together nurses, pharmacists, physios, therapists and secondary care specialists moving beyond the silo of hospital walls, so that patients can be properly and more appropriately be provided care in the community.
But no, this does not need us all to be salaried by one organisation, no this does not need us to give up elements of our core funding and no it does not need us to give up our independent contractor status.
One of the key factors pushing GPs to the edge is the skyrocketing cost of indemnity. It’s as if we are all taxed for the privilege of being a GP. It’s not surprising that some young doctors look at this massive annual bill and decide to work in hospitals instead and it’s not surprising that it’s a factor in whether many GPs can work out of hours or whether they cut their working commitments.
After pressure from GPC, the government have listened, and we secured a commitment to a state backed indemnity scheme. It’s a scheme that will include all GPs – partners, salaried and locum GPs. It’ll include our practice staff and it will cover in and out of hours NHS work. It is a major step forward but there is much that needs to be done to make it a reality. Rest assured, we will do all we can to deliver this scheme and ensure that GPs are no longer penalised just for being GPs.
Conference, the crisis is with us, the task is urgent but the solution is clear. General Practice is the foundation on which the NHS is built but it is a foundation that is cracking and weak. If we want to deal with the many problems facing the NHS we have to save General Practice.
Removing the burden of indemnity, delivering an expanded workforce team, dealing with unsafe workload levels, having premises and IT systems fit for the 21st century and crucially having the recurrent funding to sustain what we do, these are the things that will Save General Practice. This is what the government must do. This is what we will fight for.