Professor Martin Marshall: RCGP conference speech in full

In his keynote address at the RCGP annual conference 2021, college chair Professor Martin Marshall paid tribute to GPs who made the 'ultimate sacrifice' during the pandemic, discussed challenges facing the profession and hopes for the future. Read the speech in full below.

RCGP chair Professor Martin Marshall

Good morning.

It’s such a privilege to be here as chair of our college, even more so because this is the first time I have been able to speak to conference in person.

Little did I realise what was in store for all of us when I took to the stage as chair-elect at our last face-to-face conference two years ago to outline the college’s priorities: addressing workload; reinvigorating relationship-based care and supporting practices to adapt to new ways of working.

The past 18 months have been massively challenging for all of us, in particular the families, friends and colleagues of those GPs who lost their lives to the pandemic in the line of duty.

I want to pay tribute to Dr Abdul-Razaq Abdullah, Dr Addorreza Sedghi, Dr Augustine Obaro, Dr Craig Wakeham, Dr David Wood, Dr Fayez Ayache, Dr Habib Zaidi, Dr Kamlesh Masson, Dr Karamat Ullah Mirza, Dr Krishan Arora, Dr Krishna Korlipara, Dr Mohinder Singh Dhatt, Dr Poornima Nair, Dr Saad Al-Dubbaisi, Dr Syed Zishan Haider, Dr Thomas Oelmann, Dr Yusuf Ismail Patel, and any other colleagues who paid the ultimate sacrifice. This roll-call is heart rending and reminds us all why we should all be so proud of our specialty.

GPs at their limit

Anyone who’s heard me speak at virtual conferences during the past year will appreciate that I’m running out of adjectives to describe the way in which dedicated GPs and practice teams have risen to the monumental challenges resulting from the pandemic, challenges which have at times pushed us to our limits.

While politicians and the media were focused on Intensive Care Units, GPs were getting on with the ‘day job’, embracing technology and transforming our ways of working so that we could continue to deliver care and services to our patients.

GPs have cared for those most vulnerable to the virus – the shielded, those in care homes, minority ethnic communities, those at the end of life and those in deprived areas. The success of the COVID-19 vaccination programme has been largely down to your efforts. We’re managing our patients with long-term symptoms of the virus and supporting the growing backlog of patients on waiting lists. All of this in addition to delivering care to the millions of patients every week who present to us with conditions unrelated to COVID.

On behalf of your college, a huge thank you to you all. You are phenomenal.

In turn, I hope you’ve felt supported by the college throughout the crisis. Never has the need for an effective professional body been greater. We redesigned the exam to enable nearly two thousand newly qualified GPs to enter the workforce. We lobbied successfully for the temporary suspension of CQC inspections of practices in England and the introduction of a lighter touch appraisal system. We developed a dedicated COVID hub of resources on our website which has been viewed over a million times.

We’ve worked with politicians and policy makers in all four countries, ensuring that they’re aware of the challenges being experienced by grassroots GPs, for example the need for investment in technology and the disproportionate impact of COVID-19 on Black, Asian and minority ethnic clinicians and communities. We successfully lobbied government over access to COVID-19 testing and confidentialty of personal data .

Agenda setting

Despite having to prioritise the ‘here and now’, I’m pleased that the college has also in recent months been able to publish three agenda-setting policy reports, on remote care, relationship-based care, and an action plan to address the workload crisis. Focusing on this forward-looking work alongside meeting the immediate needs of our members is important for a professional body. So too is our commitment to the big societal issues facing us, in particular sustainability, and equality and diversity.

But whilst doing this essential work we unwittingly find ourselves at the centre of a public storm over face-to-face appointments. The malicious criticism of the profession by certain sections of the media and some politicians as a result of the shift towards remote working - introduced to keep our patients and our teams safe and keep the service operating - has been the worst I can remember in over 30 years as a GP.

This widespread vilification of hardworking GPs and our teams is unfair, demoralising and indefensible. No one working in general practice deserves this abuse and your college will continue to fight on your behalf until we get the support we need to provide the best possible care without risking the safety of our patients or jeopardising the health of our teams.

And the so-called support package for general practice in England announced this morning is most definitely not the answer to the challenges that we face in providing high quality care for our patients. Calling today’s announcement a missed opportunity would be the understatement of the century.

At times of crisis we need hope that things will get better, so let me now turn to the future.

Even before recent events, I know that many GPs were finding it hard to be optimistic about the future given the massive challenges that we face. Many of the GPs I trained with have recently retired. Some of them are saying that they got out just in time, it’s downhill from now.

But I disagree. I point out to them that ours is not the first generation to feel that way. I remind them of the maxim that things may not be what they used to be, but then again they never were. General practice has emerged from bad times in the past and I’m confident will do so again.

If we look back over the last 70 years since our college was founded, we see cyclical highs and lows. The lowest of points in the early 1960s - a time when 20% of GPs actually did emigrate to work in Canada, New Zealand and Australia because conditions were so bad in the UK - led to the 1966 Doctor’s Charter, a massive investment in staff and premises. The lean years of the 1990s led to the 2004 GP contact, another significant investment in our teams and our data systems.

GP crisis

Sadly history tells us that things get pretty bad before politicians wake up and understand that a crisis in general practice quickly leads to a crisis in the rest of the NHS - and a crisis for their constituents. It’s frustrating that this has happened yet again despite our college calling out the emerging problems repeatedly for nearly a decade, led initially by our then chair, now president-elect, Dame Clare Gerada.

Rosemary Stevens, a medical historian, said that if general practice didn’t exist, it would have to be invented. She’s right and our job as the current guardians of general practice, is to both keep what’s good about our specialty and to adapt and change.

Our challenge is that the evolution of general practice is now happening at a faster pace than has ever been seen in the past. In his book Future Shock the social commentator Alvin Toffler described how society is changing, how we travel more and faster, we contact more people and have shorter relationships with them, how we’re faced with an array of choices among styles and products which were unheard of the previous year and may well be obsolete or forgotten by the next. He says that novelty, transience, diversity and acceleration are what modern society is about. And general practice is part of that society, we can’t stand still and we aren’t doing so.

Looking at how general practice has evolved in recent decades, picking out the main trends, gives us a pretty good idea of what general practice will look like over the next few decades. And it helps us to understand how to influence the trends. I can see 5 ways in which general practice is changing.

First, and most obviously, increase in scale. We’re shifting from small independent practices to larger organisations, based on diverse business models from voluntary collaborations to international corporate entities. The front end of general practice, what patients experience, must remain local and personal because that’s the essence of our specialty. But that doesn’t mean that we can’t also experience the benefits of scale, benefits which general practice has missed out on in comparison with our colleagues who work in hospitals.

Scale doesn’t inevitably deliver efficiencies, certainly not in general practice where our business model has led to a remarkable level of good will - a free asset to the exchequer. But I do believe that operating at scale allows us to develop an infrastructure to support our work – an infrastructure to support better facilities, better use of data, better CPD, better training and better occupational health services. General practice has got to get big in order to stay small.

Multidisciplinary teams

The second trend is increasing multidisciplinarity. When I started my career as a GP partner about 85% of the consultations in my Exeter practice were delivered by GPs. Now 45% are delivered by doctors, the rest by our growing range of primary care professional colleagues.

The flexibility and cost-effectiveness of the expert medical generalist is something we mustn’t dismiss. But the broader primary care team brings new expertise to patient care in the community and working as part of a multi-disciplinary team is professionally fulfilling.

General practice will remain highly multidisciplinary and we’ll progressively work more closely with our disease-based specialist colleagues currently working in hospitals. And at the same time we will continue to put pressure on politicians across the UK to make good on their commitments to increase the number of GPs. We need more GPs.

The third trend is the development of a new kind of relationship with patients. General practice has never been comfortable in the doctor-knows-best space. We’ve always promoted the consultation as a meeting of experts, a place where trusting relationships are facilitated and decisions are shared. This shift, possibly the most significant of cultural shifts for the medical profession, will continue and speed up, led by general practice. And we’re increasingly seeing person-centred care as more than just good communication, it’s a technical skill requiring a good understanding of psychology and statistics, which needs to be learnt, practised and improved.

That’s why the college published 'The Power of Relationships' earlier in the summer and is persistently making the case that most of what we do in general practice isn’t a series of disconnected transactions.

Trusting relationships are the essence of general practice, an intervention which the evidence suggests improves health outcomes, patient experience, clinician satisfaction, and the efficiency of the NHS. If trusting relationships were a drug, guideline developers like NICE would mandate their use; they are that impactful.

Community focus

The fourth trend is the growing orientation to our responsibilities outside the consulting room, focusing on the needs of the communities that our practices serve.

There’s a growing interest in improving population health, in particular by addressing the social determinants of health. We’re appreciating that however effective the medical model is, it can’t solve all the problems we see. Michael Marmot highlighted in his brilliant conference plenary in 2019 that only 10-20% of the ill-health that we see is remediable through action by the health service. A far larger proportion of health problems is the consequence of social determinants like education, employment and housing.

I’m seeing an increasing number of practices who regard this as a practical challenge, who despite their massive workload are making time to systematically examine the most important social determinants of health for their practice populations, who are utilising social interventions, addressing health inequalities and who are drawing on the assets that exist in their communities.

Like Hill Top surgery in Oldham for example, which, when they realised that a third of the patients they referred for outpatient appointments were failing to turn up and that most of that third lived in their most deprived wards, designed a system of reminders and arranged a free patient-led transport service.

Or the Craigmillar Deep End practice in Edinburgh which recognized that they weren’t meeting the needs of socioeconomically deprived patients with mental health problems and so employed three new mental health practitioners and started running outreach clinics in their local schools.

Or the ‘outsiders-as-insiders’ model of Frome Medical Practice in Somerset which employed a homeless man as a community co-ordinator after a member of staff struck up a conversation with him on a park bench and realised he had a deep insight into how the local community worked.

Our college is shining a light on these activities and over the next few months you’ll hear more about this work.

NHS integration

And the final trend is closer integration between health and care services. The NHS was designed in silos in 1948 and by and large, worse in some parts of the UK than others, it still operates that way. This matters greatly to those who use and provide services. Patients experience the consequences of poor communication, the need to repeat information, the information that is lost, somewhere, in transit. And as GPs we know what it’s like to have to pick up the pieces.

And our governments can see the problem. To be honest, I’m not overly confident that legislation will make a massive difference to our working lives. I’ve seen a few legislative reforms over the last couple of decades; they come with a big bang and disappear with a whimper. But I do think that GPs, working with specialist colleagues, patients and NHS managers to redesign local care pathways can make a real enduring difference. We must retain a strong voice in the wider system to ensure that the services of the future are shaped around the needs of our patients and communities.

I’ve identified five trends - increasing scale, increasing multidisciplinarity, a stronger patient voice, a more significant public health role and greater integration - which I think help us to understand what general practice will look like over the next few decades. I recognise that there are some GPs who don’t like some of the trends but I think most of them are inevitable and that if we’re clever we can make them work to the advantage of our patients and our specialty.

But we will only really be able to engage with and effectively lead these trends if we’re successful in addressing the biggest challenge to general practice, undoable workload. And that’s why addressing workload is our top priority as a college, and also why I'm so disappointed with today's announcement in England.

We’re working in a number of areas to address these long-standing challenges, the most important of which is lobbying for a larger workforce. We’ve successfully lobbied for more training places and as a result of our campaigns in schools and medical schools general practice is now a highly attractive career option. We are working with our governments on specific programmes to improve retention and we are starting to see a significant increase in the number of pharmacists, link workers and mental health professionals working in practices.

But growing the workforce is a medium- or longer-term solution and the problem is now. So we’re working with BMA colleagues to reduce the unnecessary administrative work which takes us away from caring for patients – we want a lighter-touch, high-trust approach to contract management, more proportionate regulation, allowing other health professionals to sign return-to-work certificates and to have limited rights to prescribe.

Traditional role

And finally we’re working with our members to better understand the evolving role of the GP within a multi-disciplinary primary care team. The traditional model of GP-as-all-things-to-all-people was an efficient model – surprisingly so to economists who talk about us ‘working to the top of our license’ with no understanding of what we do or what our license should look like. But when demand outstrips supply the traditional model is becoming less and less deliverable in most practices. We are now seeing GPs focusing on those areas of work where they can add greatest value – triage because we’re good at managing risk and making quick decisions; managing complex biopsychosocial problems because we are experts in complexity; and adopting a more strategic role in improving the health of our communities.

So a growing number of GPs are attempting to create space by spending less time on the more transactional presentations that used to occupy much of their time and in doing so are starting to free up time to focus on the areas where they can make a greater difference.

No one pretends that this shift in ways of working is straightforward. If we’re spending more time with complex problems, we need to see fewer patients for longer. If we are taking on new roles, like public health, we need more training. If we are segmenting our work then we need a better understanding of how to differentiate between a simple problem and a complex one. And if we aren’t seeing patients for blood pressure and medication reviews, we need to better understand the impact this has on how we build trusting relationships with our patients over time.

These aren’t easy questions but practices around the country are finding answers. That’s what general practice does; driven by our deeply embedded values we adapt, we evolve, we innovate. And that’s why we should all be more confident about the future of our specialty and our patients can be confident about the future of their care.

Thank you so much for listening, thank you for everything you are doing for your patients, communities and our speciality. Things will get better.

I hope you enjoy a stimulating and energising conference.

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