LMC Conference 2016: GPC chairman Dr Chaand Nagpaul's speech in full

GPC chairman Dr Chaand Nagpaul hits out at the ongoing crisis in general practice and sets out why the GP Forward View is not enough. Read the full text of his speech below.

Conference, four months ago, in this very hall the profession declared that general practice is in a state of emergency. 

We made an unequivocal statement that day - that GPs are no longer prepared to work in an environment of unmanageable workload that prevents us providing safe, quality care to patients; one that undermines our professionalism; and which suffocates us with demeaning regulation.

This has created a toxic mix from which existing GPs can’t wait to escape, and which many young doctors will not join.

We gave the government six months to negotiate a plan to rescue general practice from the brink of irreversible collapse.

Special LMC conference

GPC has worked hard in these past four months. The special conference was a launch pad for our urgent prescription for general practice campaign. We produced national heat maps demonstrating the bleak reality of nine in 10 practices seeing an increase in workload over the past year, half reporting further deterioration in quality of care, one in 10 state they’re financially unsustainable, and almost half struggle to obtain locum cover for essential services.

The campaign penetrated the media far and wide. We made the front page of the Guardian, appeared numerous times on primetime national TV, the Today programme, and with a total of 663 mentions across broadsheets and national and regional media. Next week GPC is hosting a parliamentary event in Westminster so that MPs can confront the harsh realities of general practice with their LMC constituents.

Opinion is shifting, awareness is growing, that there is a crisis in general practice.

We heeded the call from special conference to cease bureaucratic annual contract changes. The 2016/17 contract agreement doesn’t have a single new clinical requirement. We rejected all NICE recommended QOF changes.

We reduced workload by negotiating an end to the dementia DES, a political sacred cow which distorted clinical behaviour, and we’ve transferred that money into core funding. We negotiated an uplift of £220m to the contract value - twice that of the previous year, and for the first time factored in rising expenses of indemnity and CQC fees.

GP workload

But any such positive change to the contract is totally drowned by the growing tidal wave of relentless demand and unfunded workload outside the core contract.

Unlike the disputes that have faced our hospital colleagues, our problems and solutions are not confined to changing our contractual terms, but are as much about changing the wider environment in which general practice operates.

An environment in which it feels we’re being set up to fail. Where a workforce that’s thousands of GPs short, is expected to treat an expanding older population with multiple complex needs. Where a shrinking share of resources is given to doctors facing a mountain of unresourced work moving out of hospitals. Where the organisations that support us in the community have their budgets cut, while those that belittle us with petty regulations and threatening inspections are allowed to flourish.

There’s no single magic bullet to address this. Moreover, unlike our hospital colleagues we’re not bound by a common national contract. In parts of the country half of GPs work in a sessional capacity, and that means that our solutions have to reflect these diverse career aspirations, different contractual options, and we must be inclusive of all GPs that make up our broad profession. 

With this in mind, GPC has laboured since January putting together our urgent prescription rescue plan "responsive, safe, sustainable". It’s a package of tangible proposals we believe can first stabilize the current parlous state of the profession, and further create a platform for future sustainability.

GP crisis

Since January, I’ve been through the doors of number 10’s policy unit, the offices of the Secretary of State and NHS England, putting forward our ideas about what we believe needs to happen to salvage general practice.

The government finally responded with NHS England’s GP Forward View last month. This represents a symbolic change in language by the centre, headlining pressures in general practice and the need for support and investment.

Simon Stevens could not have been clearer in the introduction, citing that UK GPs suffer greater workload and stress than their international counterparts. He explicitly damns a decade of disinvestment in general practice which saw GP numbers rise by only one third that of hospital consultants. He quotes a recent headline "if general practice fails, the NHS fails". How long have we been telling the government that?

I’ve stood on this platform before and reflected that successive governments have recognised pressures and deficits in every part of the NHS except general practice. After all our collective lobbying, media publicity and the special conference it seems our message is finally getting through.

The GP Forward View is not a single proposal, and has no fewer than 108 commitments and various funding pots. It would be simplistic to either support or dismiss it in toto, and there are several positives that we as GPC have directly influenced, and which match those in our urgent prescription.

After a decade of declining funding, general practice will finally see an upturn of investment significantly higher than other sectors, and with increased share in the overall NHS budget. This is positive, but is tempered by the fact that general practice endured gross disinvestment at a time of plenty, while the government is belatedly trying to make up the deficit at a time when the NHS is virtually running on empty.

GP access

Last summer I called on government to end its obsession with seven-day opening. It’s notable that the GP Forward View was not launched with any publicity regarding routine seven-day GP services, and the words 'seven days' or 8-8 do not appear in the document. Furthermore, our lobbying has ensured there are no changes to the contractual hours of GPs.

The Forward View states that local commissioners can decide the level of routine capacity required on evenings or weekends, and further offers flexibility for this to be aligned to urgent care or GP out of hours services. It’s not gone far enough, but in the context of a manifesto pledge that formed the basis of the government’s intransigence with our junior colleagues, we may have partly won the argument. Of course politicians will resurrect the seven day agenda but it’s vital that we hold NHS England to account to their words to ensure that the priority for seven days is where it should always be - for properly funded urgent care and GP out of hours services, and we must reject the immorality of taking GPs away from caring for acutely ill patients to sit in empty surgeries superfluous to need.

Our urgent prescription is­­­­­­­ clear that the immediate priority must be to provide stability to vulnerable practices, or practices coping on the outside but with a fragile foundation that could suddenly collapse. GPC proposed local taskforce teams to provide funding, management resources, or interim clinical cover which could be called upon at short notice. This would be in a supportive nonthreatening environment of amnesty, where practices can hold their hands up to seek support without fear of a breach notice or a CQC intervention.

It should be a significant untoward incident and a failing of the local NHS if any practice needlessly closes. This creates disruption and displacement of essential family doctor services to patients, and the domino effect of instability on neighbouring practices, not least wasted costs to the taxpayer of reproviding the service.  

I therefore call upon NHS England to use the GP Forward View’s practice resilience programme to make it an explicit KPI for all Area Teams to ensure there’s not a single unnecessary or avoidable practice closure now or in the future.

Rescue general practice

Clearly any rescue plan must at its heart tackle inexorable, unmanageable workload – this is the root cause of the desperate plight of general practice today, and a direct result of demand running roughshod over our skeletal capacity. It’s simple. We need to reduce demand, or increase capacity, or best do both.

On managing demand, the Forward View estimates that more than a quarter of GP appointments are potentially avoidable. That’s patients who could more appropriately have seen another professional or service, patients who didn’t need medical advice at all, or appointments taken up for completely bureaucratic purposes.

Just reflect on any of our surgeries – if not a quarter, we could probably agree that a conservative 10 per cent of GP appointments could be avoided.  Free up those appointments and you increase GP capacity by 10 per cent. That's before any change in actual GP numbers, and therefore it's a no-brainer that the system must do everything possible to stop inappropriate or avoidable waste of precious GP appointments.

On that note, we’re told the standard hospital contract has been amended to stop hospitals sending patients who’ve missed appointments back to their GP. That asking GPs to re-refer to a related specialty will cease. And that there’ll be an end to asking GPs to chase up hospital results, with responsibility falling upon the requesting clinician. This is most welcome, and must become a reality now - but our urgent prescription goes much further in proposing an end to a raft of other examples of secondary to primary shift, from inappropriate transfer of specialist prescriptions to ending GPs chasing up hospital follow up appointments, and it’s positive that NHS England are setting up a primary/secondary care interface group to address this perennial problem.

GP Forward View

The forward view heeds our call for a national patient self-care campaign scheduled for September. This  must deliver an unequivocal public facing message of the pressures on general practice, that GP appointments need to be used wisely and to empower patients to self-care both for minor ailments and as experts in their chronic disease, or signpost them to other services

Our urgent prescription supports GPs working together in collaborative alliances. I grew up in the days of sharing out of hours work in a rota with three neighbouring practices. When the workload became intolerable, in 1995 GPC negotiated an out of hours development fund that transformed our ability to cope, with the birth of the GP out of hours cooperative movement. It demonstrated how GPs can be imaginative, effective and do great things together when given support and resources.

Now is the time to resurrect that spirit of collectivism and mutual support. We need development funding for an in hours cooperative movement, and pull together in local communities as one GP profession. We’re seeing examples of this working already-in one instance a practice about to close after losing two partners was kept afloat by employed doctors in the local federation and is now back on its feet.  In another example a federation’s urgent care hub was able to support a practice unable to cope due to GP illness.

We must ensure the forward view’s funding for working at scale becomes a reality focussed on supporting practices and not for political expedience

Fundamental to any rescue package is the ability to put limits on workload. We must end the current unsustainable reality of GPs working to unsafe open-ended demands and exhausting non-stop days without a break. In our urgent prescription we propose maximum workload limits, and the creation of overflow hubs to support practices when that point has been reached.  Neither is it humane nor defensible for GPs to be forced to manage patients with complex multiple problems in a pressure cooker intensity of 10- minute aliquots.  GPs must be given longer consultation times in the interest of safe care, even if it means exposing a waiting list to see us.

Quality and safety

Managing workload is also about taking control ourselves. GPC has launched a new quality and safety first webpage. This will give practices off the shelf ideas and tools on how to manage workload, drawing upon examples that have worked elsewhere. This is also about empowering and valuing ourselves and pushing back on unresourced non-core work, with the support of LMCs and local coordinated strategies. These initiatives need resources and headroom, and it’s vital that the forward view’s releasing capacity funds are used for this purpose.

Moving to workforce capacity this is much more than just a number. I’ll spare ourselves the conjecture on the repeated political mantra of 5,000 more GPs by 2020. As we’ve said before, this puts the cart before the horse, since you first must create a job that doctors want to do.

Meanwhile we must surely first exploit the full working potential of the existing GP workforce. Our BMA survey shows that excessive workload is fuelling GPs turning to part-time work, with 1 in 5 GPs intending to reduce clinical sessions further. Making the job doable and rewarding will reverse this trend and itself expand workforce capacity. And with government figures stating 38% of GPs intend to quit in the next 5 years, mass resignation is not a threat –it’s an impending reality. The government must ensure we retain the current workforce, in particular tackling the perverse factors driving older GPs to leave early.

As part of this, NHS England must urgently address crippling indemnity costs. This is not just about punitive expenses on GPs compared to others doctors in the NHS. This is directly reducing workforce, with ample evidence of GPs reducing sessions while others are leaving due to prohibitive fees. The forward view’s commitment to address this must grasp that reducing the indemnity burden is a cost-effective investment to instantly expand existing GP workforce today, while we await the promise of training more GPs tomorrow.

We must also embrace skill mix to support us while we’re thousands of GPs short. When I started out as a GP, I routinely gave travel and childhood immunisations, syringed ears, and even dressed wounds. It was an inappropriate use of my time, and the expansion of practice nursing has fortunately put an end to this. Today, there are multiple emerging ways in which skill mix can support GPs, from independent nurse practitioners, the expanding role of practice pharmacists, direct access extended scope practitioners, enhanced community nurses and paramedics doing GP home visits and so forth. We need recurrent funding for embedded skill-mix not time limited subsidised schemes, and with the flexibility to meet the needs of practices rather than be constrained by political initiatives such as physician associates.

I mentioned in January the pernicious impact of CQC over-regulation. The forward view’s proposals to reduce inspections every five years totally misses ­­the point – we don't want to simply reduce the frequency of a process which is utterly flawed and damaging to GP practices. We’re calling for it to be decisively expunged and replaced with a system that’s proportionate, targeted, understands context and supports practices rather than threatens them. This is why the GPDF is funding a judicial review challenging CQC’s heavy handed processes that are neither fair, equitable nor reasonable which we believe falls foul of the basic principles of natural justice. And a system in which we’ve this week exposed that their rating of a practice correlates with its level of funding, and which penalises and shames those that are the most disadvantaged already.

On inspection fees, of course we’ll fight for these to be fully reimbursed, but the true cost of CQC goes far beyond its fees but in terms of the days and weeks of stress and preparation taking GPs and staff away from patient care, and with tens of thousands of GP appointments cancelled weekly to accommodate inspection teams. This is why the current process absolutely needs to be culled, and put millions of pounds squandered in nit-picking senseless processes back into patient care instead.

So where do we go from here?

General practice has been given a glimmer of hope but not yet a solution, recognition but not yet repair. We would be failing in our duty if we did not do our utmost to exploit the positives  in the Forward View in the interests of GPs we represent. To make sure moneys announced actually reach practices without needing to jump through hoops, that new schemes are used to relieve workload not add to our burdens, and to hold NHS England to account to make sure these are not just platitudes.

GPC is on the national oversight group of the Forward view and I’ve additionally proposed an LMC reference group to ensure high level ideas are translated into reality on the ground

We would equally be failing in our duty if we considered the Forward View as the final word in rescuing general practice. It’s not. Four months into our six months timescale, our campaign for general practice continues. We will fight for what the forward view has not tackled, where it has not gone far enough, and to implement those proposals in our urgent prescription that are missing.

Our campaign must also expose the elephant in the room which is money. While general practice will finally get a larger slice of the NHS cake, it remains a cake that’s woefully too small to feed the needs of the population. A rationed cake in which we spend less of our national wealth on health than most of the western world, where we have a fraction of the hospital beds of France and Germany and lag behind most other OECD countries in our doctor and nurse numbers.

We need an honest wider debate about NHS funding, but also about what general practice can deliver within its current meagre resource, how we can responsibly cut our cloth according to the money we spend on healthcare, and put an end to the irresponsible political pretence of offering a consumerist service on a shoestring.

Within this reality, the fightback continues. General practice matters far too much to me, you and our patients to pack our bags because the government hasn’t gone far enough. We know the decade of neglect can’t be turned around overnight, and our message to ministers as representatives of UK general practice is resolute and clear – we remain determined to rescue our proud profession and we will not give up until and when we achieve success.

Full coverage: LMC conference 2016

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