Madam Chairman, Conference,
These are exciting and worrying times. Exciting because we are at the beginning of a new venture in democracy with a government that has given much prominence to expressing a desire to engage with GPs to deliver health care. Worrying because government needs to ensure that the pursuit of major savings and efficiencies do not adversely affect patient care.
We should not kid ourselves that this Secretary of State will be a softy. He has an agenda that is full of opportunities or threats depending on the fine detail of where he takes his shopping list. It is up to us to help him shape his ideas into things that will work for patients and their doctors, that are feasible within the limits of general practice, that will develop the range of care that GPs can offer whilst remaining safe and cost-effective, and that will not destabilise the NHS we have all striven to create. He is also feeling his way with a coalition that few of us could have predicted and even fewer can be certain how their health policy will pan out.
We should remember that, while there has been record investment in the NHS over recent years, patients often do not feel that their care has improved. Going forward, Government must be determined to avoid wasteful and un-evidenced policies.
We have a list of things that should be consigned to the dustbin of history: wasteful PFI schemes, management consultants, the bureaucracy of the NHS market, management tiers that seem to exist to do little more than micromanage general practice, and patient surveys that provide no benefit to patients because they ask the public questions they may no longer remember the answers to, and cut practice income regardless.
Other things of questionable value that should be up for review include: parts of NHS Direct, the cost-effectiveness of which has so far not been properly evaluated; Choose and Book – a way to stop patients exercising their choice of hospital; the current wrongly-consented version of the Summary Care Record. And what about Walk-In Centres and Darzi Clinics? Expensive to build and staff, and, once again, their cost-effectiveness has yet to be properly evaluated. Many of them have become white elephants, under-used by patients, put in communities already well served by local practices. There should be no new polyclinics without a proper assessment of local need. It is a GP’s job to get rid of irritants and here is a good starter list for the Department to hand back to the Treasury with our blessing. If government wanted to be even more popular with GPs and taxpayers, they could allow GPs to provide better access for patients in a flexible way that improved the service for them. How about a patient-centred rather than a target-driven service? Now there’s something we could all get behind.
Moving forward, it would also be a good idea not to start spending money we don’t have on letting any patient anywhere in England register with any GP in any other part of England. The removal of practice boundaries was announced by the previous government in September – but it is something all the political parties want to see happen. The GPC is supportive of the need to improve access and choice of practice for patients, but it has highlighted the problems with this specific policy from the outset, and has developed a considered response to the proposal, which included a much cheaper alternative way forward.
We have repeatedly explained how expensive boundary-less practice is and how much it will harm the NHS and patient care generally, but politicians still say they want people in Liverpool to be able to register with me in London. If they insist, we will do it and show them how to make it work, but I ask you, is this credible patient choice or scarce resources down the drain? There is plenty of published evidence to show that patients who move home want to stick with their GP if they can, and we should try to find ways to make it possible for practices to expand their borders rather than make them infinite and potentially unstable, as well as messing up NHS finances, all of which are based on where people live.
If things go well in negotiations, we could see a model of GP commissioning that would be better for patients, enable GPs to advocate for their patients, and allow hospital colleagues to provide the best health care rather than merely be slaves to the latest government whim of a target. Not all GPs will want to commission for themselves, but many would want to be part of a group of GPs doing it in a consortium for their patients. The conversations we have with our patients give us an invaluable insight. They tell us where the NHS does, or doesn’t work for them. It means we are in the best position to ensure that the NHS works for the benefit of patients and taxpayers. If that is what the government means by renegotiated GP contract then that would be fine. As for out of hours, clearly there is a widespread feeling that we could commission it better than PCOs and we have a chance to do so – but never as the providers of last resort. We will not go back to a situation where GPs are working round the clock to provide routine care.
What if it isn’t like that and, sadly, we end up with business as usual? We have seen all this before. New government, lots of chat about engagement, then getting advice from anyone except those who represent GPs, policy by decree and announcement without any attempt to get the health service involved, deliberate briefing against GPs – including some blatant lies at times, culminating in a messed-up agreement to try to provide a massive public health service to deal with the flu pandemic – one part successful, one part failed. Do we want any of that again? No fear. The civil servants at the back of the hall today should carry my message back to government: it doesn’t have to be like that.
There some things on the horizon that we are not so sure about, partly because we have not yet seen any detail. I’m not sure we are keen on contractual responsibility for commissioning, although it depends what is meant by that. We will not welcome the greater intrusion of the private sector in the running of, or commissioning for, the NHS. We accept that the private sector is here to stay, but GPs think this has gone far enough for now and would rather see the NHS enabled to provide good service. We are sceptical about Patient Reported Outcome Measures – for which there is presently very little primary care evidence. If evidence appears that these measures are reliable, then they will go into the NICE process and then be part of QOF. QOF is meant to fund the work as well as the outcome. Practices rely on this funding stream to deliver higher quality care and to pay the staff to help them do it. Please don’t get rid of all that we have achieved for patients. The threat of a wholesale renegotiation and years of instability is avoidable.
My message to Andrew Lansley and his team is that we are ready, willing and able. What we are ready, willing and able to do depends on you. If you force us to do more for even less, if you spend time briefing against GPs, if you want to make your mark without our involvement, then we remain ready to challenge, willing to fight for patients first, and able to say what we think. If we can work together, we can make the NHS thrive, even if there is no new money. We can innovate and improve and patients will be more satisfied, better cared for, and all of this in the most cost-effective fashion.
Which brings me to the other minor issue we face: no money. GPs understand about lack of funds. Our practices have been starved of them for years. No premises developments. No way to get new GPs into the business. No cash from PCOs too scared for their own future to see the benefit of long term investment in ours. We understand about economic woes and GPs will play their part. What GPs will not do is take punishment uniquely and vindictively based on mythical stories about our contract. We conned nobody. We work hard for our money and we are not ashamed to be here. We want to provide the best care we can within the available resource and the GPC will lead GPs into whatever place will deliver that as long as our practices aren’t wrecked by it. If you want to make something happen, get GPC and LMCs involved and we can show you how and deliver it.
If GPs and LMCs are going to lead at this difficult time, despite the vast bulk of NHS spending going on hospital care and the drugs bill, we, and our hospital colleagues, will all need to pull together in order to agree, if we can, what can stop without damaging patient care. We may have to accept that some parts of patient care may have to change too. Nobody will want that, but if it has to happen, at least let us see how we can minimise the effects on our patients.
We are determined to inform our policy-making by listening to what patients, the public and the profession want. In June 2009, the GPC launched ‘Developing general practice, listening to patients’ as part of its ongoing work on responding to patients’ expectations and ensuring that the GPC continues to lead the profession in improving quality in general practice. In April 2010 we published ‘Fit for the Future’, a GPC position document covering a broad spectrum of aspects of general practice. Based on LMC Conference policy and GPC debate, this document set out the profession’s position on topical issues for politicians. This publication has now been followed by a new wide-reaching consultation of patients and other stakeholder groups on several of the key themes set out in Fit for the Future. It is called Striking a balance: what matters most in general practice? It’s time we had an honest, public debate about what is most important in general practice. We know there are big financial problems. We know the public wants more and more from the health service. We know, because we see it day in day out, that caring for our aging population is putting huge strain on the NHS. We know these competing interests mean we won’t always be able to provide everything everybody wants. So over the summer months we will be consulting widely with patient groups and the public, going out to meet them, listening to their views. And if we do not like what they say? Well, we will just have to consider how GPs can fit into the solutions they pose for us. Some might call that daring or foolhardy. I call it listening to patients. NHS managers should try it some time.
GPs have worked extremely hard over the past year to meet the extra demands imposed by the flu pandemic and vaccination campaigns. It would have been very difficult for practices to have had to cope with further contractual burdens. I hope therefore that the profession will welcome a year of relative contractual stability in 2010 and that the clinical DES extensions will give all practices that wish to do so a chance to engage in delivery of these services.
Unfortunately, 2010/11 will not be a year of financial stability. The Review Body’s recommendation of a 1.34 per cent gross uplift in the overall value of GMS contract payments was, regrettably, not honoured by the UK governments. Instead GMS contractors were awarded only a 0.8 per cent gross uplift for 2010/11, a shortfall against movements in expenses calculated to impose efficiency savings on general practice. As a result, general practice will once again be under great pressure to make ends meet in a difficult fiscal environment. While we appreciate that things are tough we feel it is unfair to use GP pay as an economic regulator. The GPC was extremely disappointed with this decision, which will inevitably result in a reduction in personal income for many providers, who don’t want to see their practices suffer.
Problems will be compounded by the fact that the small uplift will not be distributed to practices evenly. During negotiations, GPC negotiators were willing to negotiate the differential distribution of any money remaining once a flat increase had been delivered to all practices to cover expected increases in expenses. This would have had the advantage of ending some practices’ reliance on correction factor funding while guaranteeing a degree of stability for all. NHS Employers and the DH however, asked the DDRB to uplift global sum only, based on a belief that practices receiving correction factor funding do not necessarily deserve additional investment, an evidence-free piece of prejudice that the GPC negotiators have consistently challenged. The application of this year’s uplift, as recommended by the DDRB, is not limited to global sum but does mean that practices with correction factor payments will receive less than other GMS practices. With such a small gross award, all practices will be under pressure. We only asked for our expenses to be met, the DDRB supported our position and awarded us enough to keep our practices going, and the Treasury even cut that.
In addition, the trainees’ supplement was not increased back to its previous value. This is a disincentive to young doctors to join us. They are our future and deserve our support in their quest for better training experience, better pay and a stable future.
Meanwhile PMS practices in England face stringent demands from PCTs, which in turn are being leaned on by the Department to implement the new ‘quality and productivity’ agenda – an unfortunate euphemism for cuts. PMS practices, who became so in order to stop their practices being damaged by local health policy, are now being hit because they managed to survive. Although we cannot negotiate for them directly – because previous Health Ministers would not agree to it – GPC and BMA Regional Services support LMCs who represent their constituents in a climate of PCO threats and intimidation.
As general practice changes, so too must our own representative structure. Last year, the GPC established a Sessional GP Representation Working Group to consider how effectively we are serving the needs of our sessional colleagues. A huge survey of sessional GP BMA members informed the work and helped it determine how sessional GPs should be represented at a national and local level.
Last month the GPC endorsed the group’s findings and the recommendations will be implemented in full. There have been calls for our sessional GP colleagues to form a separate branch of practice within or outside the BMA. However, our survey of sessional GPs showed that the majority did not want GPs to be divided in this way. When these changes are completed shortly, I hope that sessional GPs will share my belief that they are best represented by the GPC. Their voices will be bolstered and their own control over their own future secured within the body of GPs. They will have delegated authority nationally, a secure place within GPC, proper positions on LMCs locally, and a more democratic power-base.
The H1N1 outbreak generated a huge amount of work and numerous meetings for GPs, LMCs, negotiators and GPC staff. We were greatly helped by the three years of preparation that GPC had put into the build up to the pandemic, as many agreements necessary to deal with clinical and operational aspects had already been settled. The H1N1 vaccinations DES for at-risk groups compensated GPs for the additional work involved in the immunisation campaign and offered a number of non-monetary concessions to help free up practice time. A second wave of H1N1 vaccination negotiations in late 2009, for the vaccination of children under five, failed to result in a national agreement because the Department refused to concede sufficient ‘time releasing’ measures.
NHS Employers’ negotiating mandate for 2010/11 included significant changes to QOF. During negotiations, GPC argued that it wished to see minimal changes to QOF in 2010/11 to allow practices to focus on the flu pandemic. We secured this as part of the flu vaccinations deal. As a result, the only change made to the 2010/11 contract was the extension for a further year of five existing Directed Enhanced Services (DESs) due to finish in March 2010.
The concessions secured as part of the H1N1 vaccinations DES included threshold easements for patient survey access payments in 2009/10 for those practices who reached the target uptake. This may have helped some practices with their PE7 and PE8 QOF achievement, but has not diminished the negotiators’ desire to separate the patient survey from access payments. Many practices earned less for access and for QOF in 2009 than they did in 2008 as a result of the access payments moving from a DES to QOF. We intend to discuss this issue again during negotiations for 2011/12.
Meanwhile, the DH has been busy developing the Quality, Innovation, Productivity and Prevention (QIPP) programme focusing on identifying savings and undertaking service reconfiguration to alleviate the NHS’s considerable financial pressures. Much of this will take place in secondary care, although it is likely that there will be a significant transfer of services from secondary to primary care. The GPC will continue to engage constructively with the Government over this process. However, we will not encourage specialist work to come into the community merely to save money by shrinking a local hospital. Such moves end up being more expensive and less beneficial for patients.
The role of primary care in the out of hours (OOH) period has had a particularly high profile over the past year, largely as a result of the tragic death of a patient in Cambridgeshire. The previous government conducted a review of GP OOH services with the RCGP and made a number of recommendations regarding the commissioning of OOH care, PCO Performers Lists and the selection and training of OOH clinicians. The GPC is supportive of these recommendations, and will continue to work with the Government towards achieving better involvement of local GPs in the commissioning of OOH services. We have also advised ministers regarding ways of ensuring that GPs from abroad are capable of working in the UK.
We hope that the new government is going to take a long hard look at the policies of the Summary Care Record and the Transforming Community Services programme which has forced PCTs to rush into decisions about how the division of PCT provider and commissioner functions will operate. We will help them in their review and tell them why we think these two ideas might have worked better if we had been listened to rather than consistently ignored during their recent excessively rapid implementation.
As always, the BMA’s communications and parliamentary experts have helped GPC members and LMCs to campaign hard on behalf of the profession. Much of the press work this year revolved around the outbreak of the swine flu pandemic as the BMA sought to dampen hysteria and put across sensible public health messages. The press office also provided support to the GPC during swine flu negotiations, which included dealing with a number of anti-GP leaks from different sources.
This year the GPC went to the Press Complaints Commission for the first time to complain about an article in the Daily Mail concerning GP pay (although there is plenty we could have complained about given its obsessive and unfair attacks on our profession). The complaint was resolved satisfactorily with the Daily Mail publishing a joint letter from myself and another GP. Perhaps they will try to get their facts right before they publish rather than afterwards.
Madam Chairman, a lot of activity and a very busy year for GPs who have coped with viral, political and financial pressure.
Conference, I have outlined the range of options open to the new government in this early developmental phase. GPs in general, and GPC in particular, would like to be there before policy is fully formed so that we can help shape it. We will do that whether we agree with what is proposed or not. If we are excluded, then politicians cannot be surprised if we say what we think in an uncomplimentary manner. If we can help to make the NHS a better place for our patients, they will be more satisfied, which will make government happy. If both of these groups are happy, even GPs might feel good about themselves. All the government has to do is talk to us and consider our views. If they agree with us that would be even better. We have a unique opportunity with this unusually shaped government. I hope that Conference, governments and our wider society make all the right choices. We must not miss this chance to make the NHS a better place.
Read below the full transcript of the keynote speech delivered by Dr Laurence Buckman, chairman of the BMA's General Practitioners Committee (GPC), at the LMCs Conference this morning.
Madam Chairman, Conference,