The foundation of general practice has “serious structural faults” – but can be fixed

Dr Richard Vautrey addressed a BMA members’ event this week and discussed in-depth the reasons why general practice is both vital and at risk

The BMA’s GP committee chair, Dr Richard Vautrey, has stated that the very foundation of general practice is at risk of collapse – but it can be rebuilt.

Vautrey made his statement as part of a speech to BMA members at this week’s annual conference in Brighton. He said that those foundations have some “serious structural faults”, but that he is committed to rebuilding and helping to solidify the future of the UK’s health service.

He also highlighted the invaluable footing that primary care provides for the health service, but added that it is at risk as GPs struggle with workload pressures and practices close down.

Delivering his speech at the Brighton Centre, Vautrey said:

“For 70 years, general practice has been the foundation on which the NHS has been built. For 70 years general practice is where the vast majority of patient contacts have occurred, where generation after generation have been looked after by GPs and their teams, embedded within their community, providing care even before the cradle and often after the grave to those left behind grieving the loss of loved ones.

“It’s been on this foundation of general practice, and the primary care we provide, that other NHS services have depended. We’ve managed demand, enabled efficient working elsewhere in the system, directed patients to the right specialist service, been innovative in care pathway design, and above all managed clinical risk on behalf of the NHS as a whole.

“But when nearly 40% of GPs intend to quit direct patient care in the next five years, and over 90% of GPs are reporting considerable or high workload pressures, we know that the foundation of general practice has serious structural faults.

“When instead of gaining an additional 5,000 GPs, we’ve lost over a 1,000, we know that the foundation of general practice is cracking.

“When over a 1,000 GPs have referred themselves to the new GP Health Service in England because of stress and mental health problems, or when hundreds of practices have closed and over a million patients have been forced to look for a new GP service, we know that the foundation of general practice is breaking down.

“For far too long our service has been undervalued and taken for granted. GPs’ work ethic and dedication to their patients has been exploited through a decade of underfunding and soaring workload pressure, with the assumption that the GP practice will always be there to pick up the workload that others say they cannot or will not do.

“The NHS fails to commission a specialist service, well don’t worry, the GP can do it; local authorities cut smoking cessation or weight management services, but don’t worry, just make an appointment with your GP and they’ll prescribe what you need; a new specialist care home or private hospital opens up in an area without any warning or planning, but don’t worry, the GP will pop around regularly to visit everyone; and then some bright spark comes up with a well-meaning idea that just requires the patient to get a letter from their doctor, but don’t worry because that’s what GPs are there to do, isn’t it?

“Well let me make it clear – it is now time to worry. The foundation of general practice on which the NHS is built is seriously at risk of collapsing and if the NHS wants to survive in to old age we need urgent action now. If we cherish our NHS it’s time to save general practice.

“In Scotland, this has meant over two years of work that has led to the introduction of major new contract changes this year, aiming to reduce risk and workload for practices. In Wales a second QOF suspension helped practices struggling with workload pressures over the winter. In Northern Ireland, even without politicians being prepared to get back to their responsibilities in national government, NIGPC has secured agreement for additional funding for practices and pharmacists.

“In England we have outlined what must be done, and made clear how any additional funding promised by the government as part of a long-term plan for the NHS must be spent. In our report Saving General Practice we highlighted the need for real investment that provides an additional £3.4bn recurrently each year. We need to seriously step up our workforce plans to ensure every practice can recruit a GP when they need to and that existing GPs are properly supported to encourage them to stay in the service. We need to ensure every practice has the support of a pharmacist working in their team, to not only reduce GP workload, but to improve the safety of patient care and reduce medicine related adverse incidents.

“We need to invest properly in premises, to reduce the risks for those potentially left last-person-standing and prevent bodies like NHS Property Services from pushing practices to the point of closure by their unacceptable and unjustified cost hikes. The deal in Scotland shows that something can be done about this and it is possible for the NHS to share some of the risk.

“We need a step change in IT support, enabling every practice to have reliable demand-management systems and the technology to offer smartphone consultations when appropriate, without the need to exploit the out of area registration arrangements by cherry-picking young healthy patients as a provider in London is doing.

“We need primary care support services that actually support practices and GPs, and don’t make our work harder and more difficult to deliver. The National Audit Office has forensically exposed the national scandal of NHS England’s abject failure over more than two years to sort out the shambles that they created when they privatised our back office service and left us with Capita’s Primary Care lack-of-service England. NHS England may have made over £60m savings on the deal but its practices, GPs and above all patients that have paid the price.

“We need to protect, enhance and reinvigorate our independent contractor model of working and the partnership model that gives all GPs involved a voice in decision-making, which has delivered continuity of care for generations of patients and enables GPs to be positive advocates for their patients. It’s good therefore that the Jeremy Hunt has listened to us and set up a partnership review led by Nigel Watson.

“And we also need to deal with the problem of indemnity. GPs effectively pay an indemnity tax of thousands of pounds just for the privilege of working. Securing commitments in England and now also in Wales to introduce a state-backed indemnity scheme by next April are important steps forward. All we ask is for equality with our colleagues in hospital. It cannot be acceptable for a GP to be working alongside a consultant colleague in the same community service, and for one to pay indemnity tax of thousands of pounds whilst the other has their indemnity covered by the NHS.

“A comprehensive system, that covers all GPs – locums, salaried and partners – as well as the staff who work in our practices, has to be put in place, and we will work with government to make sure this happens.

“I want to conclude by thanking the skilled BMA secretariat who support our work across the UK, the executive team and negotiating team members in the four GPCs who give up so much time to work on your behalf, and particularly to thank my colleague chairs, of GPC NI, Scotland and Wales.

“However, this will be the last ARM at which Alan McDevitt and Tom Black chair their respective GPCs, and we owe a huge debt of gratitude to both of these giants of general practice, not only for the work they’ve done in Northern Ireland and Scotland but also for the huge impact they’ve had for GPs across the UK. Thank you to both of them.

“Despite the challenges and the pressures, the government’s recent announcements show that we are winning the argument but there is much that still needs to be done.  We will not give up on our vital task to save general practice, to rebuild the solid foundation on which the NHS has been built for 70 years and work with the whole BMA to ensure our patients get the best possible healthcare for generations to come.”

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