Addressing GPs at the annual meeting of representatives of England’s 100 local medical committees (LMCs)1 in London, Dr Richard Vautrey, BMA GP committee chair, demanded an end to “sticking plaster solutions” and demanded an “effective, long-term cure” for the pressures facing the profession, urging the government to use its long-term NHS plan to properly invest in general practice.
Delivering his speech at the Mermaid Centre, Dr Vautrey said:
The days are shortening, the temperature is dropping, the lights are on and Christmas shoppers are packing the West End of London. All very predictable. And just as predictably NHS winter pressures are here again. But as we all know “winter pressure” is a mythical diagnosis, for we experience the reality. The reality is an NHS that is in a year-round crisis; the pressure is on 12 months of the year, day after day.
We know and experience this daily pressure in our surgeries. We know and experience the pressures on our patients as they need more care from us but we struggle with the capacity to be able to respond. And we know and experience the impact on our staff and colleagues, too many of whom are becoming ill themselves as they struggle with unsafe workload.
We know the illness, but our experience has shown that short-term fixes will not solve this problem. More sticking plaster solutions will just make the patient sicker. Instead we need an effective, long-term cure. We need nothing less than a properly funded NHS built on the solid bedrock of a thriving general practice.
As we try to cope with another winter, the long hot summer seems a distant memory. But you might remember a trailer on the BBC that seemed to be run at every possible moment over the summer. A new doctor was coming, and as they repeatedly said: “It’s about time”.
Now you might have thought that was a cryptic reference to the next Dr Who being female, and it’s good that the BBC is at last trying to catch up with general practice as we lead the way in medicine with now 54 per cent of GPs in England being female.
However, I’d forgive you for not realising that the trailer was really about the fact that it was about time the next Time Lord came from Huddersfield. Sadly, I think we’ll need more than a Doctor in a Tardis to keep our football team in the Premiership this year.
It’s about time. The Prime Minister has said that we have come to the end of eight years of austerity and it’s about time.
After consistent pressure from the BMA and others the Chancellor and Treasury have finally accepted the need to invest more in the NHS and it’s about time.
Never mind eight years of austerity, GP practices began suffering zero awards, pay cuts and financial pressures 12 years ago and it’s about time it ended. Over a decade of rising stress and falling morale, of spiralling workload and shrinking GP numbers. It’s about time GPs and our patients got a fair deal.
You’ll have seen this week that the media has switched on the A and E pressure checker, but we know that for every patient who attends A and E many, many more are being seen by GPs and their practice teams on a day-to-day basis. Practices across England are trying to cope with the rising workload challenge and doing their best to provide the best possible care to their patients.
And the best of general practice is the best of the NHS, with the CQC finding 96 per cent of practices are delivering good or outstanding care this year. This amazing achievement, despite the year-round pressures, is down to the dedication, skill, commitment, innovation and hard work not just of GPs but also of our nurses, healthcare assistants, reception staff, practice managers, admin and office staff and increasingly our pharmacists, physios, social prescribers, paramedics and the many others who are joining our teams, working alongside GPs to deliver world class general practice. I’m proud of them and what they achieve, often against the odds, and I know you’re proud of them too and so we should thank them.
It’s about time we had some good news for general practice and in places it is starting to appear. We are making progress.
The opening of five new medical schools in Chelmsford, Lincoln, Sunderland, Ormskirk and Canterbury, with an emphasis on community-based training, is laying a foundation to help resolve GP recruitment and retention problems in areas that have struggled for years. LMC secretaries like Dr Brian Balmer, who supported the Anglia Ruskin development in Essex, have had the foresight to commit to this and played a key role in making it happen. Well done Brian and all those who helped deliver this positive outcome.
GP trainee numbers are at last on the rise, with more and more junior doctors choosing general practice as a career. We have been involved in a number of initiatives to encourage young doctors to see that general practice can, and will, offer huge opportunities to make a difference for individuals and communities and that it’s worth committing themselves to this profession.
And, after years of cuts and attrition, we have turned the tide and now delivered a well-deserved increase in pay for thousands of hardworking doctors. And, alongside that, this year we have delivered the biggest increase in investment into the contract for over a decade, with £317m secured, and potentially more to come. For this, and for their support and work throughout the year, I want to thank your GPC England executive team of Mark, Krishna and Farah2, expertly supported by our skilled BMA staff.
You might have noticed that we’ve got a new Secretary of State for Health and Social Care. To his credit he’s listened to what we’ve said, he’s backed the partnership review and state-backed indemnity scheme work started by his predecessor, but he’s also taken repeated opportunities to underline that general practice is what the rest of the NHS is built on and depends, not least in his first party conference speech as Health Secretary.
He said: “Our GPs are the bedrock of the NHS. They’re everyone’s first port of call. We need more of them, better supported, and better equipped. Prevention of ill health is nothing without primary care. So we back our nation’s GPs every step of the way.”
No other professional group was referred to like that and they are words he has repeated many times since. He’s also added to this just two weeks ago on the Today programme when he said he “strongly agreed that we need to shift the balance of resources to primary care” and he wanted to “see the proportion spent on GP services going up”. These were words echoed by the Prime Minister yesterday. We are winning the argument on the need to invest in and develop general practice.
But these words will count for nothing if they are not matched by tangible action. They will mean nothing to the GP overwhelmed by workload pressure that is making them ill. They will mean nothing to practices unable to recruit after placing advert after advert. They will mean nothing to the patient that has lost their local GP service as their practice joins the others that have closed this year.
Following massive pressure by the BMA and others, the government has committed to invest an additional £20bn annually in to the NHS. Whilst it’s an increase, all respected health economists agree that it’s clearly not enough to cope with the needs we have to respond to. But if this vital but limited funding, as has happened repeatedly year after year, is lost in to hospital deficits and we don’t see the shift to increased investment in general practice and community-based services that the Secretary of State is promising then warm words will count for nothing. We need to see words turned in to action and we need that now.
And so the announcement yesterday by the Prime Minister3 that £3.5bn of the £20bn will be spent on primary medical and community services, with a commitment to ensure a growing share of overall NHS spending goes to general practice and community healthcare, is important for us to consider.
It may make good headlines for the public, but the devil will be in the detail and as the Nuffield Trust observed yesterday “far from representing a big shift in funding towards out-of-hospital services, this money will simply allow GPs and community services to keep up with demand over the next five years and it is not going to lead to a significant change in the way that people experience healthcare.” We already have meetings scheduled in the next few days to drill down to the detail as we cannot tolerate another five years like the last 12 and we must ensure that the crisis we face is properly addressed with real, additional and recurrent investment.
And to be clear, we cannot accept essential funding used for another hundred micro schemes that wrap us up in bureaucracy, leave practices wondering where the money has gone and patients no better off. We must see new funding used effectively, with practices in control so that we can start to address workload pressures and deliver a safer service to our patients.
Perhaps whilst the Secretary of State is on a roll he could also try sorting out Capita’s PCSE and the delays with NHS Pensions. The government have belatedly seen what was obvious to everyone else and decided to no longer commission PFI projects because they’re not good value for money.
Well perhaps they ought to learn the lessons and stop outsourcing essential NHS back-office services too, as Capita’s running of PCSE has proven to be an unmitigated disaster.
Practices and individual sessional GPs have had to cope with failure after failure, and whilst we’ve managed to sort out many of these problems and get some of the basic systems back on track, now we’ve seen one of their worst failings of all, with them not sending out over 43,000 invitations for smear checks and worse, not informing over 4,500 women of their results, potentially leaving some of them at risk. How bad can it get before NHS England gets its act together and sorts out a mess that they created? They can outsource a service but they cannot outsource their responsibility.
And whilst this goes on, their wider failures have left many GPs in pension limbo, with no confidence that payments have been recorded and processed properly, with no statements to confirm what’s been done and so leaving some GPs at risk of additional tax payments over which they have no control. This is completely unacceptable and cannot be allowed to continue.
It’s no wonder that so many GPs are reducing their clinical commitment in order to reduce their risk. But they are also doing this to help manage workload pressures, to help get their head back above water, to achieve a better balance in their professional lives and to be able to sleep better at night because the risk of mistakes and errors has been reduced.
But let’s get one thing straight, calling a GP part-time who works five or six intense, stressful, almost never-ending sessions a week is an insult. These GPs who still work more hours than most people do in a week need our praise and thanks, not off-hand and unwarranted criticism.
GPs are right to take steps to work in a safer and more sustainable way. It’s the way to enable more of our colleagues to stay in the profession rather than leaving altogether. But another way is to build up the team of people that work around and support GPs and to have more people sharing the workload burden.
I’ve repeatedly called for a pharmacist in every practice, with the necessary recurrent funding to make this possible and there are positive signs that that is starting to happen.
We’re also seeing practices supported by paramedics delivering a variety of home visiting schemes, physios employed to be the first point of contact for patients, and social prescribers directing patients to community services that can make a difference to them and reduce their need to attend their practice so often.
And increasingly the right type of technology can help too. GPs have been at the forefront of IT developments for decades. When it works and brings benefits we’ll run with it. We’re often just limited by the lack of investment NHS England makes in basic infrastructure, such as broadband capacity and necessary software. But we are also repeatedly let down, with at least seven major systems failures in recent months, all too often leaving practices to pick up the pieces with little or no help being provided by NHS England or many CCGs. They are all too quick to judge and blame but far too slow to step forward with support.
But when technology is used as a Trojan horse to undermine some of the core elements of British general practice, we’ll stand against it.
This year has seen the rise of GP at Hand, but through our lobbying and actions more and more policy makers and politicians are waking up to the damage their model of working could do to community based general practice. Most practices would want to be able to offer smart phone video consultations if they had the bandwidth to support it as it’s probably safer than the many telephone consultations we already do. But none of us are in the business of turning away patients who are too old, or frail, or sick, or mentally ill.
We deliver a comprehensive, holistic service, catering for all people whatever their needs. And we embed our service in a local community, with staff from that community, not from a call-centre in Soho. If NHS England is serious about supporting the development of primary care networks, of developing a genuine collaboration of local health care providers working together with a common aim for the benefit of people in their community, then they must scrap the out of area registration regulations that are exploited for profit rather than delivering comprehensive quality care.
Primary care networks, building on and supporting constituent practices, could help us to restore the primary healthcare team this conference has long called for. It could reconnect us with community nursing staff and enable us to work in a way that brings mutual benefit.
But there’s a much bigger beast potentially on the horizon. The threat of so called integrated care providers (ICP), which is a resprayed accountable care organisation, is real and should not be underestimated. Be under no illusions, entering in to an ICP agreement is a one-way street to loss of independence, direct management control and potential wholesale privatisation. It would bring to an end 70 years of NHS general practice that our patients value so highly and it would be an end to the partnership model of working.
The partnership review, ably led by LMC chief executive Dr Nigel Watson4, has demonstrated the importance of the partnership model which delivers holistic continuity of care to millions of people. But it’s a model of working that is supported not just by partners, but also by salaried and locum GPs too, because when working well it provides for a thriving practice that benefits everyone. But as the review has identified, and as we know all too well, this model is under serious strain.
We need urgent action to reduce the risks that partners are exposed to – the risks of unlimited workload pressure, of workforce management, recruitment and retention, of premises liability, of coping with unreasonable complaints and litigation, of being left to deal with GDPR and unfunded SARs requests and of course of coping with the spiralling cost of indemnity.
Following our lobbying, the government listened to us and commissioned the partnership review. Now they must not just listen to its conclusions but take steps to act.
The first and most significant step will be to deliver a state-backed indemnity scheme for general practice. For far too long GPs have borne an unfair burden of rapidly rising indemnity costs, and the system is now unsustainable. It’s a major disincentive to work as a GP or to expand our clinical teams. We have to deal with this issue once and for all and we will do that. We have worked hard to get to this point and we will not give up until we have delivered a new state backed scheme in April next year.
NHS England is about to launch its long-term plan, an outline of how it will be focusing on services over the next 10 years. No doubt it will talk about improving cancer services, investing in mental health services, improving A&E waiting times and all the other areas you’d expect.
But if there is any hope of this 70-year-old NHS safely getting to 80, NHS England and the government must invest in general practice.
Their commitment, at long last, to turn the tide and deliver increased funding flowing towards general practice and community care is essential, but if it does not deliver in a meaningful way it’s our patients who will suffer.
If hospitals are to cope in the future, we must invest in general practice.
If prevention is to be the focus, we must invest in general practice.
If we want a healthy future, and a population that has the confidence that their local GP service is there for them when they need it, then we must invest in general practice.
We’ve heard lots of talking; we’ve had plenty of promises; now they must do it.
It’s about time, and it’s time to act now.
Notes to editors
The British Medical Association (BMA) is the voice of doctors and medical students in the UK. It is an apolitical professional organisation and independent trade union, representing doctors and medical students from all branches of medicine across the UK and supporting them to deliver the highest standards of care.
- LMCs are local representative committees of NHS GPs and represent their interests in their localities to the NHS health authorities. LMCs interact and work with – and through – the BMA’s general practitioners committee as well as other branch of practice committees and local specialist medical committees in various ways, including conferences. Note that LMCs are not regional BMA offices.
- The BMA’s GP committee executive team are Dr Richard Vautrey, Dr Mark Sanford-Wood, Dr Krishna Kasaraneni and Dr Farah Jameel.
- Read the BMA’s response to the funding announcement here.
- Dr Nigel Watson is leading an independent review into how to reinvigorate the partnership model, in collaboration with the Department of Health and Social Care, NHS England, the Royal College of GPs and BMA. More information can be found here, and the BMA’s response to the interim report can be found here.