Exclusive: Shadow health secretary Heidi Alexander interview on the GP crisis and junior doctor strikes

Primary care is underfunded, understaffed and undervalued, says shadow health secretary Heidi Alexander, and the government must come up with the funding to end the GP crisis as a matter of urgency. Speaking exclusively to GPonline, she discussed pressure on practices, the junior doctor strikes and new models of care - read the interview in full below.

Q: What message are you taking from the GPs you've heard from since becoming shadow health secretary?

'In the six months I have been in this job I have been contacted by a huge number of GPs, and the postcode of the surgery may be different, but the message I am getting is pretty consistent, which is that primary care is underfunded, understaffed and it's undervalued.

'The implications of this is that it's bad for patients because patients tell me they struggle to get a GP appointment. But it also has knock on impacts across the NHS as a whole. So A&Es are getting busier and busier.

'I know GPs are under incredible pressure in terms of workloads and I think that the term crisis is often bandied around in political circles but when it comes to general practice I think that description is spot on.'

Q: You’ve said that primary care needs more funding. The current government says it is increasing funding. How much more is needed?

'One of the key problems for general practice at the moment is that there simply aren't enough GPs. And at the last election the Labour party set out some very clear proposals about how we would fund new staff including 8,000 additional GPs. That was the £2.5bn Time to Care Fund that would have meant more GPs, more nurses, more care workers. 

'I think at the moment, the deal, the financial deal that Simon Stevens secured in the comprehensive spending review is unravelling pretty fast for the NHS. We know that probably half of the additional £3.8bn for next year is going to disappear into paying the bills in hospitals from last year. 

'We know that there is an extra billion pounds worth of pension costs. And so I think what we are seeing at the moment is resources being sucked into the acute sector to the detriment of primary care. Not only is it unsustainable but it's also a false economy.

'I think the government need to think hard about the proportion of overall NHS spending that goes into general practice.

'A decade ago we know that figure was about 11%. And I think it has fallen to just over 7% now. So if we can't get the resources into the settings responsible for the largest number of patient contacts then we are going to have a problem, because it just heaps pressure on other parts of the system.

'So what I want the Labour party to do over the next few years is to understand exactly what the scale of the problem is, to have a conversation with the public about what some of the different options might be with respect to funding a sustainable NHS and care system.

'But four years is a long way away. And I think there is going to be a lot of water go under the bridge with the NHS during that time. So It think it would be an unwise person to make commitments today in 2016 about what the potential solutions in 2020 are.

'But it is clear that the NHS and general practice is in a real state of crisis at the moment and the government urgently need to come up with a credible long-term plan to sort the problems out because this is having a direct impact on patients.'

Q: Thinking about what this government should be doing right now, is the best way of getting more funding into primary care about shifting resources out of secondary care, as some people argue, or is it about finding new money? 

'I think the system as a whole is under very significant financial pressure and I think there is a question about whether the overall funding pot adequately meets the healthcare needs of a growing population. And so when you consider the fact that in 2016 we have less GPs now per head of the population than we did back in 2010. We have an ageing population. We're clearly going to have a problem in terms of how you provide that care. 

'Obviously hospital bosses need to be able to pay their staff and keep the lights on, and pay for medicines. But the pressure on hospitals is only going to grow if you don't adequately fund primary care.'

Q: On workforce: you’ve mentioned Labour's commitment at the 2015 election to recruit 8,000 new GPs. And you've been quite critical of the chances of the government meeting its target of 5,000. What more should be done to ensure that target is met?

'One of the problems we have at the moment is a real problem with morale across the whole of the primary care and wider NHS workforce. We know that applications to become GPs are dropping. I don't think that the junior doctors dispute is helping with any of this, of course. If we face the mass exodus of junior doctors to other countries that reduces the pool from which GPs are ultimately drawn.

'I also think that when you look at the age profile of the GP workforce, with I think a third being over the age of 50, and one in 10 over the age of 60. Then we actually really need to think about how we can keep hold of the GPs that we have got for as long as possible. Clearly, they are some of the most experienced GPs as well. But if we don't reduce the burdens placed upon GPs and this sense that they are just completely overworked at the moment, then we are going to be losing more and more staff from the profession.

'I think in the current circumstances we can't allow that to happen. So, I think, the government, when they come up with their expected plan for investment and support for GPs, they really need to think about how they support the workforce. A happy workforce means healthy patients. So addressing that crisis in staff morale in primary care is absolutely critical.'

Q: The government’s commitment to ensure seven day access to routine GP appointments by 2020 for all patients in England: is that an aim you support?

'I think anyone who has any contact with the NHS would like to know that they have consistent high quality, easily accessible services, when they need them.

'What is interesting is that in some of the pilots for extended GP opening times, we've seen that demand at certain points of the weekend is quite low. And so some of those pilots have subsequently been abandoned.

'I do think that there is a desire amongst the population to be able to see their GPs early evening on a weekday and certainly to be able to get GP appointments on a Saturday.

'I think [RCGP chairwoman Dr] Maureen Baker, it is probably reasonable for her to ask the question, do people really want to go and see the GP at teatime on a Sunday?

'What I'm also concerned about is this whole idea that we are simply stretching the resources available over five days of the week to cover seven days a week, which then calls into question the impact upon services during the week.

'I think if you want to enhance the level of service available you have to ensure that there are adequate resources and adequate staff to provide that service.'

Q: Is there also a role for government and politicians around managing patients expectations and demand? You talk about people's desire to see their GP in the evening or weekend, but there is that challenge in providing that. So should government be managing down demand and expectations sometimes? Or should the service just be funded to meet demand?

'I think some of the things the government is doing at the moment may increase demand on GPs. If you consider the potential closure of 3,000 community pharmacies as a result of the funding cuts in that area, I think GPs will be really worried about that.

'I think there is probably scope to think about how individuals may provide more care to themselves. And to reduce the number of times in which people have to go to GPs.

'But I also think there needs to be better join-up between a whole variety of primary care services. Because, I think of my own grandmother who sadly passed away a couple of years ago. She had multiple long-term conditions and towards the end of her life she had a carer who came in to see her, the community matron came in to see her. She was routinely in and out of A&E. She was also seeing a GP. And while there were lots of people who had contact with her, I often felt that we never really got to the root of the problem. And so I think some of the work being done in looking at how you improve integration of care in the vanguards is really important because we need to find a way of actually improving the quality of care that is provided to individuals and that sort of situation. Which may ultimately result in a more efficient organisation of the overall system.

'I read a very interesting article on GPonline about the work that's happening down in South Hampshire, an interview with Dr Nigel Watson and the work that they're doing in New Forest to integrate care, to provide a branch surgery at the hospital where people might go for a GP appointment at any point between 8am and 8pm, 24/7. I think some of the work that they're doing, bringing specialists from the hospital into the community, actually there is the potential there for a really interesting development of how you might organise primary care services.'

Q: So you support that general trajectory of policy towards providing primary care at scale, with federations, networks, new care models etc? 

'I think primary care is under enormous pressure at the moment and so I do think we need to consider how we might do things differently in order to provide a better quality of care to patients. So I'm going to be really interested in what the evaluation of some of these new models of care show. What I am quite conscious of however, is that when you talk about integration, it won't necessarily save money. Because if you're talking about having coordinators of care employed to join up different services, there's probably a salary attached to that position. And that's not to say that it shouldn't be happening. Because I think the experience for the individual could be enhanced if you are able to join up those services, more convincingly.

'My job as shadow secretary of state for health is to not only hold the government to account on the fundamentals of resourcing, of staffing. But is also to be open to new ideas about how we can deliver services differently so there are it better outcomes for patients. But hopefully a better way of organising the NHS at the same time.'

Q: I think there is a concern from some GPs and others that the development of primary care at scale, federations, new care models and eventually accountable care organisations could provide an opportunity for the private sector move further into the NHS. Is that something you have concerns about?

'I think with respect to private sector involvement in the NHS overall, the public are rightly very wary of the involvement of private companies in the delivery of NHS services, because the public want to know that taxpayers money is going into patient care and not lining the pockets of shareholders of private companies.

'And I am concerned about the way in which the involvement of more private companies fragments the service and I think the challenges of providing care to the twenty-first century population we have are not going to be met by breaking up the NHS. It's got to be about getting different parts of the NHS and social care system to work better together and so I am going to be keeping a very close watching brief on all of these developments because I think the public want to know that they will have timely access to high quality care and that taxpayers money is being used in the most efficient and effective way possible. And I think that it's my responsibility to hold the government to account on that.'

Q: Also on the idea of primary care at scale and federations and that direction of policy, there are some GPs who are concerned about the risk of losing the benefits of small scale practice, the continuity of care, the personal, relationship based general practice which many patients want. Many patients say they prefer smaller practices. 

'Continuity of care is critically important, especially for older people, for young mums and dads with small children. But I don't think that there is necessarily a one size fits all solution to any of this. Because, for a lot of working people who may struggle to get to see their GP, actually the idea that you might be able to pop into the local hospital where a GP was collocated would actually be quite an attractive option. If somebody did need that sort of support.

'So, I think what we have to make sure is that any new models of care that emerge address the needs of the local population.'

Q: On the junior doctors dispute. You’ve accused Jeremy Hunt of picking a fight with junior doctors. Why do you think he’s done that? What do you think is his motive? 

'I really struggle to explain why Jeremy Hunt has taken this approach. Because I think at a time when the NHS is facing incredible challenges, to pick a fight with the people who keep the NHS running just seems the totally wrong priority.

'My concern is that he wished to set a precedent about the definition of unsociable hours in other NHS contracts. So if you can reduce the amount of the weekend to which a premium pay rate applies in the junior doctors contract then the question is what other contracts can you change. I think a lot of NHS staff on Agenda For Change contracts are quite fearful about this.

'He claims this is about improving the consistency of care in hospitals over seven days of the week. The sad irony of the situation of course is that junior doctors are the people who are already working weekends, already working nights and bank holidays. When the health secretary appointed Sir David Dalton to lead the negotiations at Acas, Sir David Dalton, a very respected chief executive of Salford Hospital, said that junior doctors were the staff group who needed to change their working patterns least in order to provide seven-day care.

'So I am at a total loss as to why Jeremy Hunt is pursuing this, unless it is for the reasons I mentioned and this is about saving on the pay bill over the duration of this parliament.

'I think the priority now is for Jeremy Hunt to find a way back to the negotiating table. Because a prolonged period of industrial action, the further erosion of staff morale and the mass exodus of junior doctors to countries such as New Zealand and Australia is no good for anyone, least of all patients.'

Q: You have said you support the junior doctors and oppose the imposition, but do you actually support them taking industrial action, taking strike action?

'Nobody wants to strike. Least of all those junior doctors. I support the cause the junior doctors are fighting for which is a contract which is fair for junior doctors and safe for patients.'

Q: Some junior doctors say they would like Labour to explicitly support the strike action, like sixty-odd percent of the public do, and that would be useful to them in their campaign. 

'I think that junior doctors around the country are clear about the support that I have given them, whether in parliament, dragging the secretary of state to the house of commons to answer questions, on the television interviews I have given, I have consistently said that the way these negotiations have been handled has been absolutely appalling and I think Jeremy Hunt will probably come to regret some of the decisions he has taken. I'm clear in my support for the cause that the junior doctors are fighting for.'

Q: But not the strike itself? 

'This has got to be about what Jeremy Hunt will do now. He has got to get back to that negotiating table because a prolonged period of industrial action is no good for anyone.'

Q: GPs are awaiting news on the government's promised primary care policy package, hoping for a rescue package. What should the government ensure is in that announcement? 

'I think fiddling at the edges with contracts is all well and good, but I think there needs to be a proper plan, which means primary care as whole is properly funded, properly staffed and given the priority it deserves.'

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