Two months after taking on the role of BMA council chair - the union’s top position - Dr Chaand Nagpaul is in a relaxed mood as he meets GPonline for one of his first interviews in the post, and keen to set out his analysis and vision.
The former GPC chair, who has sat on the BMA’s ruling council since 2008, was elected unopposed to the top job by his colleagues. That, he says, is a ‘huge privilege’, which comes with ‘high expectations’ that he wants to deliver on for the whole profession.
‘It means for me the opportunity to influence and I hope lead change that would make the NHS a place where doctors are enabled to do their jobs properly,' he says.
His election, after four years leading the GPC, comes as the focus on general practice within the NHS and from policymakers has arguably never been greater. That is partly as a consequence of the crisis in the service and a belated recognition of the linchpin role general practice can play in saving or transforming the NHS.
Politicians across the UK and across the political spectrum now acknowledge the importance of general practice, the BMA chair says.
This puts Dr Nagpaul in a good position to lead the whole profession, he says. What is good for general practice right now, is good for the whole NHS and the whole medical profession.
There is no division within the BMA on the issue of supporting general practice: all branches of practices are ‘supporting the cause’, he says. ‘There really is this understanding that that that if we can enable general practice to deliver what it needs to deliver, it will help the entire system.’
A properly-resourced NHS
The north London GP says the idea that the different branches of practice within the BMA have separate, competing interests is ‘erroneous’. The saying coined by seventeenth century poet John Donne that ‘no man is an island’ could not be more true than it is within the NHS, he says. Not only are all the medical professions interdependent, he argues, but that integration in practice is a rebuttal to the idea of ‘robbing Peter to pay Paul’.
General practice will only be properly resourced when the NHS as a whole is properly resourced, Dr Nagpaul says. ‘At the heart of the problem is that we have an NHS that spends £10bn less than equivalent leading nations.’ Politicians cannot expect to get away with that.
The BMA collectively will argue for a properly-resourced NHS, which will ‘give us the opportunity to give general practice its rightful proportion of funding within a larger overall cake’.
It has been ‘clearly illogical’ to try to force investment in general practice ‘at the expense other parts of system when the other parts system are broken’, Dr Nagpaul says. And that itself is damaging to general practice as resource constraints and ‘brutal performance management’ in secondary care drive further inappropriate workload shift to practices. The thinking in the BMA is right, he says, ‘we now need to move into into much more active role in enabling change to happen’.
Challenging the government
In his last speech as GPC chair at the BMA’s annual representative meeting in June, Dr Nagpaul told the profession that the general election result, which returned a weakened minority Conservative government, was a ‘mandate’ to end austerity in the NHS.
‘There's no doubt the general election has has significantly challenged the government's approach to austerity,’ Dr Nagpaul tells GPonline.
The result showed the public is ‘no longer persuaded’ and no longer willing ‘to be sold the lie that you can provide more and more for less and less’.
The new chair says the BMA’s role must be more than lobbying government; it has to ‘activate awareness’ among patients and the public, working with other organisations and stakeholders.
‘Everyone except politicians seems to be agreed that the NHS cannot carry on the way it is on its inadequate funding,' he says.
‘Wherever you look everyone is in agreement that we've come to a point where it is not just illogical, it's morally wrong to try and run a health service, and pretend you can run a health service, that provides a comprehensive service without providing the resources.’
Dr Nagpaul sets out a strategy of exploiting the government’s weaknesses. He gives the example of competition regulations which compel NHS commissioners to spend time and money tendering for services. Those regulations are governed by EU competition law, which Dr Nagpaul argues, must now be challenged in light of Brexit. The ‘excuse’ of EU law ‘can no longer be the case’, he says.
In a move seen as a concession to demands from within the NHS, the Conservative party in its election manifesto admitted the internal market can ‘fail to act in the interests of patients and creates costly bureaucracy’. A Tory government, it said, would review the system and make necessary changes.
‘We need to go back to government and say "you yourselves have acknowledged the unhelpful impact of the internal market – we need to now put an end to it",' says Dr Nagpaul.
‘We have a moment in time where even the government itself is acknowledging the folly around the market. I do think now is the time we need to be challenging head on.’
Tackling pressure on doctors
Another priority for the BMA under Dr Nagpual’s leadership will be ensuring proper recognition of the pressures doctors work under.
‘It's unacceptable that doctors are working in an environment where they feel they cannot provide safe quality care and yet in that same system they're regulated and judged without that context being understood,' he says.
Dr Nagpaul says it is ‘critical’ that NHS organisations and regulators recognise the often ‘impossible constraints’ doctors are placed in by the system. Rather than ‘wave sticks’ at them, employers and regulators should support doctors when system pressures mean they cannot deliver the care they want to.
‘GP feel that they're under scrutiny, they're under threat, they're being judged, they've been performance judged, when in fact the wider environment that is the biggest impediment to quality of care isn't being addressed,' he argues.
In October last year, the GMC said it would develop a 'light touch' approach to regulation to help alleviate the pressure faced by doctors. Dr Nagpaul says the BMA will be pressing the GMC to act on this.
Progress in general practice
While arguing that general practice can only be properly resourced when NHS funding as a whole rises, Dr Nagpaul - who was elected GPC chair in 2013 in the wake of the imposed contract - nevertheless points out the progress made for the profession under his leadership.
Around 90% of the demands of the imposed contract were reversed within six months, he says, including three enhanced services, with a further four scrapped in subsequent years.
The GPC also secured an increase in core funding from £65 to £85 per patient. On top of that, he says, ending the discretionary and ‘arbitrary’ system of payments for maternity leave and sickness leave for practices was an important righting of a wrong that previously left practices at risk of £66,000 per absent GP a year.
Something Dr Nagpaul is ‘particular proud of’ from his tenure leading the GPC is the Quality First programme - a set of tools, guidance and support to help empower GPs to manage their workload. That empowerment, he says, has ‘in many ways resurrected the independent contractor status of GPs’ who, unlike other doctors, have the ability to control their and shape their own work.
He also highlights changes to secondary care contracts to try to reduce inappropriate workload shift. He says GPs now have the tools and levers to begin to reverse decades of inappropriate workload transfer.
Under his leadership the GPC also successfully saw off 'significant' government attempts to impose seven-day working on the service, says Dr Nagpaul. 'We managed to successfully resist contractual changes to our opening hours,' he says. Not only that, he adds, but in response to the GPC’s arguments, NHS England also rowed back from the idea of a ‘blanket’ 8-8 and weekend access model. ‘I think that's been a considerable achievement’, he says.
In addition, over the past few years the profile of general practice, recognition of the pressure the service faces and the vital role it plays have been raised significantly, Dr Nagpaul says. The media, politicians, policymakers and the public all have a better awareness of general practice.
‘I think those are all very important achievements,' he adds. ‘The one thing that still needs to happen is that, in spite of all of that, general practice will suffer the effects of an NHS that is under-resourced.’
‘Whatever we've achieved - like increasing the global sum considerably - general practice's pressures will not be sorted unless we sort out the wider environment in which [it] operates. And that's something that in my current role I'm obviously able to much have a greater influence on than I did before.’
