Interview: Time to stand up and defend general practice, says Dr Jackie Applebee

In Edinburgh last month, for the second year running the annual LMC conference voted to ballot for collective action over the GP crisis. For the second year running, the motion was proposed by Tower Hamlets LMC chair, Dr Jackie Applebee.

The motion backed in 2016 by LMCs, rejecting the GP Forward View as inadequate and calling for a ballot on industrial action and undated resignations, was eventually shelved by the GPC after NHS England accepted the BMA’s Urgent Prescription rescue plan as the basis for further talks.

A year later, LMCs have reiterated that the GP Forward View is not enough, and demanded a ballot. The proposal from Dr Applebee this time was for a collective list closure, to protect patient safety.

Over mint tea at a Lebanese cafe in the East End of London, Dr Applebee tells GPonline she is ‘much more hopeful’ this motion will be turned into action. The two-thirds vote in favour in Edinburgh, she says, shows there is ‘still a huge strength of feeling’.

‘I just think, we can’t not do anything twice,' she says. ‘We didn't do it last year. The profession has waited. Everybody's saying nothing's changed.’

GP career

Originally from south Wales, Dr Applebee trained as a GP in the East End in the late 1980s and has lived and worked in the area ever since, first as a partner before a career break during which she cared for her young children and became a full-time political activist, before returning to general practice in 2008.

As well as representing Tower Hamlets GPs as LMC chair for the past three years, Dr Applebee sits on the GPC where she represents members of the Unite trade union, a role she says is about representing those doctors who want the GPC to take more radical action to defend general practice.

The plans for collective list closures were designed as a specific action GPs could take without breaching their contracts, says Dr Applebee. As independent contractors, taking industrial action is complicated for GPs, and legal opinions are often waved around in the debate. Dr Mark Sanford-Wood for the GPC executive warned LMC reps voting on the plans that the way the co-ordinated action was proposed was likely to breach GPs’ contracts and the BMA could be seen as encouraging that.

But Dr Applebee argues the action would not be a breach. ‘We can do that,' she says. ‘Especially if it's on the grounds of patient safety, which is what it would be. There are protections.’ She argues that GPs should have confidence and recognise that if they don’t take action now, it could be too late.

‘If they're nervous about it, how much more are we going to take? What more has to happen before we will do something radical about it? Because, actually we are collapsing. There won't be a general practice service to defend if they are not prepared to stand up and defend it now.

Collective action

‘I think people are prepared to do it,' she says. ‘It always takes somebody to lead doesn't it, and to show the way. It's doing something collectively makes us much, much stronger. And government would have to listen.’

Despite what Dr Applebee calls the GPC’s ‘very cautious’ approach, she believes there is a ‘groundswell for action’ among LMCs, and even more so at the grassroots of the profession. One argument GPC leaders have put forward is that that surveys of the profession have shown there isn’t support for action, but Dr Applebee believes a ballot would demonstrate the reverse.

Firstly, she says, BMA surveys have been worded to engender caution. And secondly, she adds, at this stage the profession has ‘nothing to lose’ by balloting because the current strategy isn't working. Using a poker metaphor Dr Sanford-Wood appealed to LMC reps not to reveal their hand to the opponent. But, says Dr Applebee, ‘you have to at some point. If you don’t, you can’t win.’

She characterises GPC’s current strategy as ‘to keep negotiating with Jeremy Hunt and Simon Stevens' but believes it is 'too cautious about judging when talking is getting nowhere, and when to start using some leverage’.

While there have been concessions won by the GPC, in the GP Forward View, agreements on CQC and indemnity funding, for example, Dr Applebee says they are ‘little crumbs of comfort’, not the solution required to save the service. The GPC’s strategy of negotiation has ‘got us not very far’, she adds. GPC chair Dr Chaand Nagpaul has acknowledged that even if the full £2.4bn annual uplift promised in the GP Forward View by 2020/21 came now, it would leave the profession short of funding.

NHS privatisation

As well as arguing for more radical action, Dr Applebee says the role of Unite within the profession is to argue to maintain a public-service orientation and resist the pull of commercialism and privatisation. Unite GPs were among those arguing against a motion passed at LMCs conference calling on the GPC to explore co-payments. GPs wouldn’t feel forced to think about charging, says Dr Applebee, if the service was properly funded and they could see a way forward.

The doctors section of Unite, formerly the Medical Practitioners’ Union, while small, has seen its membership double since the junior doctors’ strike. Dr Applebee, one of two Unite representatives on GPC, says it is important for progressive doctors to organise as part of the UK’s largest trade union alongside other health workers.

Representing Tower Hamlets GPs is ‘fantastic’ says Dr Applebee. ‘When I go to LMC conference and stand up and say we need to collectively close our lists, I know Tower Hamlets GPs are behind me.’ But, Tower Hamlets’ reputation as a hotbed of militancy precedes her, she admits. ‘I think some of [the other LMCs] think we’re bonkers.’

The East End borough, one of the most deprived areas in the UK, does deserve its reputation for politicised GPs, says Dr Applebee. Partly that is about the East End itself - a historic centre of radical politics and protest - and the kinds of people attracted to work in public service here. ‘You can't help but be politicised working around here and seeing the conditions in which people live.’

But, she argues, it is also about organisation. ‘People say to me on GPC, "it's not like it is in Tower Hamlets everywhere else". But when something happens we do come together. But I don't think it's beyond the wit of other other areas to do that. We've got great communication systems, and I think that's all it takes because, you just have to fan the flames of somebody's discontent.’

NHS politics

But many GPs in the area are politically active beyond medical and health politics. ‘Lot of us are involved in other things, and lots of us are politically active in other ways. So I suppose campaigning is something that is second nature to us.’

Dr Applebee talks about the late East End GP, writer and socialist Dr David Widgery as an important influence on her and other Tower Hamlets GPs. ‘It was incredible hearing him speak. I thought, I wish I could speak like that man. And I wish I had a grasp of the issues like he has.’ Known as much as an anti-fascist activist and writer for the radical and underground press as he was a GP, following his tragic death in 1992 Dr Applebee says he left behind a legacy of politicised GPs which lives on today and continues to attract people to the area.

As well as its reputation for political militancy, Tower Hamlets is often held up by NHS and policy leaders and even ministers as an example of excellence in primary care. The two are connected, argues Dr Applebee. ‘If you've got the energy and enthusiasm to campaign for better social conditions, [you] are going to have the energy to innovate as well,' she says. ‘If you look at who the innovators are, they're also the same people who are out there campaigning for better social conditions and for the NHS.’

And those enthusiastic GPs have in turn influenced the local GP training programme, ensuring that many more enthusiastic young doctors choose to stay in the area. Dr Applebee herself came from south Wales to study medicine at Barts in 1981, joining the Tower Hamlets GP VTS in 1988 before becoming a partner at a Bethnal Green practice and becoming course organiser of the training scheme.

In 1999, though, she quit the practice. ‘I thought partnership isn’t for me,’ she says. ‘I didn’t like being an employer.' And she left general practice to raise her children. During that time out she became politically active in the anti-war movement, even running for election to the local council. Now, she says she would rather be on the outside campaigning, ‘able to say what I believe’, than in the chamber, ‘having to temper what I say’.

After eight years away, ‘I thought, what am I doing this for?  I'm a GP for God's sake. So I went back.’ She returned as a salaried GP in 2008 to the practice she still works at, and brought her experience into medical politics: first elected to chair the local GP forum, then to the LMC and then as LMC chair and GPC member for the last three years.

Asked what first attracted her to general practice, Dr Applebee talks about the the ‘camaraderie’ of the profession. ‘I really didn't fit in the hospital,' she says. ‘I hated the hierarchy.' General practice was an opportunity to work in the community, building relationships with people and their families and the ability to work holistically, seeing people’s social as well as their medical problems. Like her politics, general practice is about ‘the bigger picture’, she says. ‘There has got to be a bigger picture than working in the bubble.'

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