A profession under siege: how LMC conference votes will help general practice

As the dust settles on this year's UK LMCs conference, Neil Roberts explores how the key decisions will help GP practices that are facing an uncertain future.

After the media hype, petitions and protests, the democratic representatives of UK GPs, meeting for the annual conference of LMCs in York last month, overwhelmingly rejected proposals to charge patients for GP services.

But while mainstream media coverage focused on the fees row, other motions passed by LMC members to guide GPC policy for the year ahead could have a critical impact on the future of general practice.

In his first address to the conference as GPC chairman, for which he earned a standing ovation, Dr Chaand Nagpaul repeated his view that governments must recognise general practice as the solution to the challenges facing the NHS, not the problem.

Calling for a 2.5% increase in the proportion of NHS funding spent on general practice, Dr Nagpaul said: 'I'm asking government to decide whether it wants a sustainable future for the NHS. And if so, the question is not whether it can afford to support, invest in and develop general practice. The real question is, can it afford not to?'

The imminent danger of MPIG cuts closures and the looming threat to PMS practices weighed heavy on the conference.

Dr Nagpaul said protecting practices was the GPC's 'immediate priority', and suggested that government could find money to support threatened GP practices.

A motion on MPIG and PMS cuts deplored the damage done to services, criticised inadequate support and called on the GPC to 'seek to negotiate specific funding for practices with particularly vulnerable populations'.

Representatives passed a further motion asking the government to ensure reviews to funding formulae reflect the particular needs and circumstances of local populations.

'Off-formula' negotiations

The GPC is already in talks with NHS England over a new funding formula. Dr Nagpaul revealed that negotiators were arguing for a new arrangement to avoid practice funding being placed solely at the mercy of any particular formula. This would place a proportion of funding 'off formula' to temper any future swings.

Any new formula developed should also better reflect the needs of populations with high levels of inequalities, deputy GPC chairman Dr Richard Vautrey told GP.

The GPC also plans to look for a mechanism to protect practices serving vulnerable populations, such as homeless people. These practices may struggle to remain viable under a national funding formula.

Anger at the 0.28% funding increase that followed this year's Doctors' and Dentists' Review Body (DDRB) pay review, which was supposed to fund a below-inflation 1% pay rise, led LMCs to call on the GPC to consider whether it should continue to participate in the DDRB pay review process. LMCs called the DDRB report 'unacceptable'.

GPC negotiator Dr Peter Holden told the conference that GPs were 'outraged' by the review body's recommendations on expenses.

'It knows damn well what expenses are,' he said.

But Dr Vautrey says the GPC nonetheless 'certainly intends to engage with the DDRB' in the next pay review. He says the profession should think about whether the alternative of direct negotiations with government would deliver a better outcome. The GPC will try to ensure the DDRB has a 'much better understanding' of GP expenses, he adds.

GP pay under scrutiny

Meanwhile, plans to publish GP take-home pay, agreed in the 2014/15 contract, should go ahead only once the accuracy of the figures is verified, conference agreed.

Dr Holden said this was an opportunity to correct national media coverage of GP pay, with its 'continuous mixing up of gross turnover, with gross profit, with net pay'.

Currently GPs' average earnings are published by the Health and Social Care Information Centre, and include all income, such as cost rent, training, dispensing and private income, whereas hospital consultants have only their NHS pay published.

A like-for-like calculation undertaken by accountants commissioned by the GPC had put GPs' pay equal to that of a staff grade NHS doctor, Dr Holden told the conference. 'We are not going to let it publish until we have got it verified to the standards we want,' he said.

Ahead of the conference, as the GPC launched its 'Your GP Cares' campaign to tackle the crisis in general practice, Dr Nagpaul said LMC representatives would give the GPC a steer to 'find a way forward from an intolerable workload burden'.

Evidence gathering

The LMCs' call for the GPC to gather evidence on safe workloads had already been answered: GP leaders are currently looking for a mechanism to accurately measure work output.

The profession may be divided over co-commissioning of primary care, but LMCs backed a motion that was highly critical of NHS England's plans for CCGs to take control of GP contracts.

While most welcomed greater co-operation between CCGs and area teams to develop funding for practices, GPs at the conference feared CCG control of practice contracts and performance management.

Despite the warnings, Dr Vautrey believes this could become a reality and the GPC vows to oppose any attempt to give CCGs powers to performance-manage practices.

He insists the conference showed the GPC was in tune with the concerns of the profession and that LMCs support its approach.

'But they were very much highlighting concerns about workload, workforce and the unsustainability of the current funding for general practice,' he said. 'And that's why we launched the (Your GP Cares) campaign, to try to address those issues.'

The launch of this campaign and Dr Nagpaul's high-profile open letter to new NHS chief executive Simon Stevens on the eve of the conference may have quelled demands from some quarters for tougher action from the BMA.

But the next year will undoubtedly be a crunch period for the future of general practice. From the scale of the challenge identified by LMCs, the GPC has a tough task to find answers to the current crisis.

CALL FOR CHARGES

Calls to introduce charges for GP services were rejected by LMCs, which said it would destroy patient trust in their doctor.

Wiltshire GP Dr Helena McKeown, who proposed the motion, said a fee could help to emphasise to patients the value of GPs. 'A fee, for some services, to some people, would sustain us, while we build up a workforce who want to join us, and make general practice more attractive than retirement or general practice abroad,' she said.

But while LMC leaders supported part of the motion that said general practice was 'unsustainable' in its current format, and voted in favour of the UK government defining the services that can and cannot be accessed on the NHS, they rejected fees for GP services.

Dr Laurence Buckman, former GPC chairman, warned that passing the motion would 'appal most of the public and profession' and that patients would see it as 'the final nail in the coffin for the NHS'.

Speaking after the vote had been taken, GPC chairman Dr Chaand Nagpaul said: 'Introducing a financial transaction would undermine the trust between doctor and patient.'

GPs REJECT SEVEN-DAY OPENING

In a key vote at the conference, LMC representatives vowed to oppose the concept of 8am to 8pm, seven-day routine general practice care.

Wirral LMC member Dr Richard Williams proposed the motion and said there was no evidence of any need or demand, or that extended hours would ease pressure on emergency departments.

He said GPs were already struggling to provide 8am to 6.30pm, five-day cover, and extending that would need a massive increase in recruitment and resources.

Dr Nick Morton from Norfolk and Waveney said GPs should not reject the 8am to 8pm concept, but that it would need to be properly funded.

However, Southwark LMC's Dr Claire Lloyd said in an 'ideal world where there was unlimited financial and workforce resources, it would be to offer routine GP care seven days a week, 8am to 8pm. But we do not live in this sort of world.'

GPC chairman Dr Chaand Nagpaul warned about part of the motion that said GPs would agree to provide seven-day cover only if resources were provided, the vote on which was subsequently lost. He said: 'If you want to put your resource into convenient access seven days a week, it will be at the price of access to those who most need us.'

Nevertheless, LMCs voted against the concept of a seven-day, 8am to 8pm general practice service, opposing a key drive by ministers and NHS managers to improve access to services.

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