BMA ARM 2015: Dr Chaand Nagpaul speech in full

GPC chairman Dr Chaand Nagpaul addressed the BMA's annual representative meeting (ARM) on Wednesday, calling for investment to drive a 'renaissance' in general practice. Read the speech in full below.

Dr Chaand Nagpaul: general practice is on its knees
Dr Chaand Nagpaul: general practice is on its knees

It pains me to share with you the parlous plight of general practice today.

The triple whammy of morale, workload and workforce pressures I spoke about last year has become endemic. The Health Education England Taskforce has officially declared a 'GP workforce crisis' – their words not ours - and the Centre for Workforce Intelligence believes present GP numbers are 'unsustainable…to meet current demand'.

The BMA's recent biggest ever survey of 15,000 GPs signals a catastrophic workforce timebomb ready to explode, with one in three GPs intending to retire in the next five years, and one in five GP trainees intending to leave the NHS to work abroad.

It would be utter folly to dismiss this as shroud waving - not least because the government’s pledge for 5,000 more GPs during this parliament will be pointless if we lose 10,000 GPs in the same breath.

Video: watch Jeremy Hunt unveil new deal for GPs

We’re fundamentally paying the price of the systematic underinvestment in general practice for at least a decade - the recent words of Simon Stevens himself, reducing from 11% of NHS spend to now about 8%, and with the proportion of NHS doctors who are GPs shrinking from 34% to 26%.

And this unashamed starvation of general practice has come as GPs have taken on the greatest growth in volume of care compared to any other sector in the NHS, seeing an estimated record 370m patients per year - up 70m compared to seven years ago.

The irrefutable fact is that demand has absolutely outstripped our capacity, and we simply don't have the GPs, appointments, staff or space to meet these escalating demands, set to increase further with a growing older population, and tranches of care moving out of hospital.

This has resulted in unsustainable workload, at a punishing pace and intensity. GPs work flat out 12- to 14-hour days without a break. We manage complex patients often with four different chronic problems, trying to condense an hour’s worth in the impossibility of 10 minutes, given they were previously seen in four different hospital clinics. We look after seriously ill patients at home who would otherwise be in a hospital bed.

If GPs carry on the way we are, we're putting not only ourselves but our patients at risk of care that’s lacking in quality and potentially unsafe."

We laboriously record a wealth of data on computer screens we’re performance managed on. Add to that the avalanche of phone consultations, hundreds of patient letters and test results daily, each of which could have serious consequences on a patient's health, let alone the rigours of running a practice with increasing regulatory scrutiny. This intolerable pressure-cooker environment is driving many GPs out of the profession, and leaving growing numbers of practices struggling unable to recruit and handing back the keys to government.

It’s no wonder that junior doctors are shunning a career in general practice - with continued unfilled GP training places, since when they experience general practice, far from the myths peddled of lazy GPs working office hours, they see the diametric opposite of doctors overwhelmed from open ended demand, working longer hours than many hospital shifts, and taking work and worries home with them at night and weekends.

This should concern all of us, since an insufficient GP workforce will have shattering repercussions on the rest of the NHS. Today, 16 times more patients will attend a GP surgery compared to those who’ll attend A&E. Therefore each practice closure, each unfilled GP vacancy, each GP working fewer sessions due to stress or each retiring early will significantly reduce GP appointment capacity, and a mere 6% reduction in patients seen in general practice would double the numbers attending casualty if they went there instead, and we could be talking not of a four-hour wait but an eight-hour one.

But there's a serious undertone to this. If GPs carry on the way we are, we're putting not only ourselves but our patients at risk of care that’s lacking in quality and potentially unsafe with alarmingly nine out of 10 GPs stating that workload pressures, and lack of time are damaging quality patient care.

General practice 'on its knees'

RB, this has to be turned around for the sake of patients. The only deal fit for general practice is one that will one that will lift the profession off its knees from the weight of unsustainable workload, not keel it over with more burdens, a deal with gives us increased core resources to do our jobs properly with enough time with patients to provide safe quality care, with more nurses, pharmacists, and healthcare staff to support us now not promises of targets in 2020.

A deal that doesn’t just give golden hellos to under-doctored areas when the truth is the entire UK is under-doctored when it comes to GPs. A deal that rids us of the suffocating effect of disproportionate CQC inspections taking doctors and staff away from patient care.  A deal that manages demand on a fragile GP service, and doesn’t stoke it. And one that stops general practice being exploited as a one way valve of unresourced workload shift and the backstop for every problem in the NHS and beyond.

A deal that values the unstinting work GPs do - not the jibes portraying us as working 9 to 5 when we work flat out dawn to dusk, starting earlier and finishing later than most routine NHS services. And recognises that GPs already work seven days a week, 24/7, 365 days a year - so don’t insult the thousands of GPs working tirelessly throughout the night and weekends seeing ill patients at 2am in the morning or on a Sunday afternoon, and visiting them at home if they need.

And at a time when the government says we’re 5,000 GPs short, when the Centre for Workload intelligence says we haven’t the GPs to sustain current demands, it’s simply unrealistic and illogical to expect GP surgeries nationally to be open routinely seven days a week. This will damage quality by spreading an inadequate GP workforce so thinly, and replace continuity of care with impersonal shift-work, and take GPs away from caring for older vulnerable patents.

And given nowhere in Europe offers state funded routine seven-day 8am to 8pm GP services, is it moral that we should use a deficit NHS budget profligately when we can’t afford cancer treatments available in other nations, and when the government’s own seven-day pilots showed empty waiting rooms on a Sunday afternoon with one Yorkshire scheme closing due to insufficient patient demand throughout the weekend? The government should instead properly resource woefully underfunded  GP out of hours care, overhaul NHS111 into a fit-for-purpose clinically-led service, and develop an integrated urgent care seven-day service so that so that acutely ill patients can be confident of getting access to a quality GP service day and night.

Fundamentally the government must invest in a renaissance in general practice, so that it’s a regeneration zone with a bright future, with a manageable and rewarding workload where GPs have the time and tools to reconnect with the joy of being GPs providing holistic care to patients. Only then will a new generation of doctors want to become GPs, and existing GPs want to remain working so that we can revive, rebuild and safeguard the future of our unique and proud family doctor service admired the world over. RB, I move.

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