Speech by Dr Laurence Buckman to the LMC Conference 2008 - 12 Jun 08
- Extract From : http://tinyurl.com/57rqqp
Dr Laurence Buckman, Chairman of the BMA's GPs Committee
Keynote speech to the LMC Conference 2008 - 09.50 hrs Thursday 12 June 2008
Madam Chairman, Conference
This has been an interesting year. GPs have continued to suffer from a government that seems not to value what we do and is intent in offering our work to someone else. Each month has brought a further turn of the screw. The government almost wears our discomfiture as a badge of pride. They should be ashamed. This level of mutual mistrust does no-one any good. It is bad for society, corrosive to the body politic and dreadful for our patients. GPs just want to be left to get on with the job of healing the sick. I would like to persuade GPs to trust the government again, but I doubt that our goodwill will be earned back easily.
I suspect it has been interesting year for the government too: They cannot have liked being defeated in a Judicial Review and having a massive nationwide campaign mounted against their policy for NHS general practice. We haven’t finished either.
I have been greatly supported over the past year by my Deputy Chairman Richard Vautrey, my fellow negotiators: Peter Holden, Stewart Drage, Chaand Nagpaul and our Celtic colleagues Dean Marshall, David Bailey and Brian Dunn. As well as them, we have an outstanding team of policy executives, media experts, economists, parliamentary lobbyists, pensions advisers and lawyers. This large group is backed by the GPC and the rest of the BMA. Without all of these people behind us, we would never be able to do what we do. I am grateful to all of them.
Although it is invidious to name individuals, I will pick out three whose presence has made my job easier, and trained me for the chairman’s role: firstly Sue Marks, the retiring head of our Parliamentary Unit. She has educated me often and supported me always. She was here before I arrived as a boy at Conference and her contacts and advice have been invaluable. Secondly, Linda Millington, Head of Media Relations in the Public Affairs Division has been my mentor and moderator ever since I became a negotiator. Her skill and energy, as well as her wise counsel, are an example to all. A generation of negotiators have learned so much from her. I thank her too and wish her well in retirement. Finally, I must thank the man who has been my exact contemporary forever and who, but for a little local difficulty, would have been standing here today. Hamish Meldrum, our chairman of Council, my friend and now our leader. He has set a standard that is hard to match. I thank him for his support this year.
In the past 12 months, the assault on GPs everywhere has intensified. When I said that we should keep politicians out of the day to day running of the NHS as they had their own agenda that was not always in tune with patients’ needs, I got slagged off on the floor of the House for being the “worst trade unionist since Arthur Scargill”. I don’t even have his hair style. I meant what I said about politics and politicians – the NHS should operate in an apolitical environment where patients come first and their legitimate needs are not subverted by politicians’ wants.
The next trick for number 10 was to say that the BMA does not know what grass roots are thinking. Let’s just remember who received 97% and 3% of the GP vote. Let us make sure that the civil servants at the back of the hall remind their masters of the GPC poll result that 97% of GPs think that the present government is messing up the NHS and that we do not support what they are doing to it. I think I am on safe ground with 97% support don’t you?
On the other hand, 84% patient satisfaction with our extended hours is seen as outrageously tiny and presumably the reason for insisting on a rigid scheme to make GPs sit in surgeries in the evening and weekends. If wider society is changing and the 24 hour culture is taking over, then the government had better find a way of resourcing this workload – especially if they are going to offer so much to the private sector to deliver it.
So let’s look at the scorecard that GPs and the government have between them:
GPs:
- Essential Services - delivered
- Quality and Outcome Framework – delivered
- Enhanced Services – delivered
- Additional Services – delivered
- Efficiency gains – delivered
The Government and the contract:
- MPIG guarantee - broken promise
- Pensions - broken promise
- Guaranteed Enhanced Services Floors - broken promise
- Equitable PMS Return - broken promise
- Contract Imposition only in "national emergencies" - broken promise
How about some honesty? The government spin machine decides to attack GPs. They organise a biased survey. Have your cake and eat it. “Would you like your GP to be open day and night and at weekends?” No mention of the effect this will have on other services, no mention of the cost, no thought about what this will do to patients who are satisfied with what GPs already offer. Even with a survey that would have pleased any South American dictator, GPs still get 5 out of 6 patients to support them. What is a politician determined to bring competition into the NHS to do? “I know, let’s try force”. So what does the new prime minister promise when he comes into power? Less knife crime, better wheely bin emptying? No. His first guarantee is that GPs will be open for longer. We told government that over 50% were willing to do this, but even then the spinners were busy saying that GPs were refusing to work in extended hours.
There are many of us who would have liked another alternative to the two dreadful contract choices we were forced to consider for extended hours – “you can be hung or shot”. The GPC did not offer you other choices in our poll because the government made it clear that there were none. Is this how to communicate, through a megaphone - do this or else? The NHS depends on the goodwill of its workers. The government was very unwise to throw it away as they won’t get it back easily. The rigid DES they imposed is unsafe, unfair and unworkable and of questionable value to the few patients who want it. Is it a wonder that I say that the NHS should not be there to benefit politicians?
So what does benefit politicians? Saving money that patients won’t notice so they can spend it on something they will. Boy, will patients notice the new commercial health service. For generations, GPs have wanted access to diagnostics and physio. Now suddenly, we are going to get these but only with private sector involvement. Who is the government listening to? Those who work for the private sector that’s who. Who offers help to PCTs to decide how to commission? The private sector, and often the same organisations that provide services.
You lucky Celts. Your ministers, all from different political parties, have come together and announced they want none of this agenda. They want their NHS to flourish without an incessant battle and commercialisation. In
The reason our patients will have to put up with this commercialisation of the English NHS is that the government analysis about GPs is that we are not required and that what voters want is a fast service from anyone. Let me tell the government what patients already know: any GP will not do. Patients come to us because they see us as providing continuity – something that matters to many. When asked how long we spend with patients we can say “25 years”. The government is chucking this away at their peril. Once the private sector is offering a service to see any doctor in a hurry, this priceless knowledge will be lost forever.
Let’s bust another Alternative Provider Medical Services myth. Anybody can bid for APMS. Come on peeps. You need a bidding department to get in quick in the land of swift procurements. Only large organisations used to bidding can do that in the required time. Whatever the government may say, some PCTs are convinced that only the private sector will get a look in and that they should offer it to the corporate provider who can underbid against any group of GPs. So much for choice. Who will be damaged by this rush to bring in commercial competition? Patients will be damaged when they get a quick and cheap service with minimal quality. I know “The quality will be guaranteed”. Not if they have to turn in a profit it won’t. I know “GPs are private businesses”. Actually, customer satisfaction with GPs is high because the GPs all work in the business and for it. How many shareholders, or executives, work in the practices that have been handed over to the private sector?
Why is the government trying to offload parts of the NHS? Is it so that everyone can be blamed other than the government when things go wrong - like they have done with the railways? GPs do not fear fair competition from the private sector, wasteful of taxpayers’ money though this is. What we fear is the utterly vertical playing field on which we are being forced to compete. The NHS should be putting money into GP premises and staff rather than PFIs for the benefit of private shareholders. It will cost the country a fortune over the next 25 years. Better premises are the key to the better services GPs are itching to provide. Perhaps government can explain why PCOs have starved NHS GP premises of funds over the last five years?
Let’s look at “GP-led health centres” which will often be commercially-led clinics employing GPs. We are told that “one size does not fit all” but we know that all PCTs must have one. We know that many PCTs do not want one but they are going to have one so the only possible debate is where they will be. What if patients do not want one, what if nobody wants one? Tough, as every PCT will jolly well get one.
Ah polyclinics. A fave of all of us and probably OK in some places where there is true local consultation and agreement. How do we feel about vertical integration, this strange notion that GPs will become the front of the hospital to keep people out of A&E and to also act as junior doctors on the wards? How do we feel about so-called community specialists, a place to dump underemployed post CCT fellows who ought to get consultant jobs but who will see patients who refer themselves directly? This dumbing down of general practice will spell the end of the generalist who can offer holistic care. It will see the rise of clinics further away from the patients they serve and providing much less of the personal care and commitment they value. It will see the rise of doctors in primary care who will know a lot about bits of the patient but not much about the family in context. This will be bad for these doctors and GPs and most importantly bad for the patients. Who could have dreamed this one up? Someone who knows nothing about primary care. The government would do well to remember that the independent Kings Fund issued a report last week telling them that there was very little evidence to support polyclinics and that they thought they were a bad idea. No doubt they will be ignored as the government continues along its evidence-free path. What a way to run a health service.
Hence our campaign. You asked for it and we have delivered it to you. GPs are standing up for their services and their patients. Without our patients’ support we are nothing. What better than a celebration of NHS general practice in the 60th year of the NHS. At 2 o’clock today I will be proud to knock on the door of Number 10 and hand in a petition signed by over 1.2 million people in
If the government won’t listen to you, their doctors, then surely it will listen to 1,236,085 men and women who call for a halt to the plans to promote the use of commercial companies in general practice. Voters don’t want funding to move from GP practices to commercial companies who are accountable primarily to shareholders rather than patients. They want to be treated as patients, not customers.
My message to Gordon Brown is this: Whatever you think of GPs, take note of what your electorate think. We’re not saying we’re perfect. We want to improve. But work with us to do that, not against us, and ignore at your peril the wishes of the most important people in the NHS – the patients.
I want to warn those who think that we will make a loud noise today and then go quiet. Our campaign does not end today. We are going to tell our patients exactly what is being done to their NHS until the next election and beyond. Gordon Brown has yet to phone me at 6am to tell me he is listening to me.
One of our pre-occupations next year must be what to do for the next generation of GPs. As if it wasn’t enough to damage the trainees’ supplement last year, the DDRB, egged on by government, are still out to reduce the small incentive to become a GP even further. Now the government is going to charge junior doctors to sleep in the hospital. Is it a wonder that the entire profession feels under assault. Although many GPs want to be non-principals for family or other reasons, many do not choose to be sessional doctors. New GPs want to be brought to the workforce as partners or permanent staff, not roving locums. All of us must find a solution to the problem of how to accommodate our successors into meaningful roles. We must give them a feeling of belonging, not just looking in. I realise that this is not easy in the present climate but we have to do this for our own sakes as well as theirs. Our patients need good doctors and there are plenty of underemployed ones out there. All of us need to think how we could add one to our own practice establishment. We will lose the next generation of family doctors at our, and our patients’, peril.
If we are trying to bring on future GPs, where better to start than with their education. We want a full 5 years in GP education, based in primary care, not just another load of service fodder, but really being trained to work in the new NHS. We must have funding protected for the whole five years. GP training is not an option or a luxury and it has to be done properly by those who know how to do it. GP educators must train future GPs and be properly funded to do so.
One of the main ways the NHS could develop, and here we agree with the government, is through better use of Practice Based Commissioning. This has not taken off universally because many PCTs are unenthusiastic and unhelpful. Arranging care collectively with patients and managers could be really good if it were allowed to flourish. Commissioning care could be the way to protect ourselves from predation by commercial outfits and would also optimise what patients would receive from the NHS. We want to encourage this as a way of keeping the NHS public.
Now I would like to turn to the myths about our pay. Picture the scene in 2003. All the money we used to receive as our basic practice income was turned into the global sum. Contract negotiations continued, when suddenly, the percentage of our future pay that was to be put into performance related pay was raised by ministers against our advice. We said “this will distort things”. They said “We will never give you more money just for doing what you do now.” They added “You will never get 900 out of a 1000 QOF points”. I recall going into my surgery and showing them how well GPs would do. They did not believe me. They insisted on defunding Global Sum which meant that 90% of us had to get Correction Factor or face underfunding and in the worst cases go bankrupt. This MPIG arrangement was brought in by agreement with all four governments, and the express approval of the Chancellor of the Exchequer at the time. Now who was he? I can’t quite remember. He certainly signed off every aspect of our pay deal and the MPIG that he is now so keen to get rid of. Let me remind everyone of the words of John Hutton - the minister at the time - Correction Factor is there in perpetuity until it is not needed.
Let this be understood by those who insist that MPIG somehow cements health inequalities into our resources. It does no such thing. MPIG is historical funding that reflects where we were in 2003. If the government had played fair with us, then we would have had sufficient resource rises that would have helped to reduce our dependence on MPIG. Our pay is based on workload, not neediness of patients, although these are clearly linked. We also want the money to go where it was intended: to those who have the hardest workloads. We also want to see the reworking of the QOF funding arrangements to remove all the corrections that were introduced, as these have had an unfairly distorting effect on QOF distribution.
Of course, the government does not understand why we are GPs or what patients get from their GP. Their thinkers say “Surely, if I need antibiotics I should just be able to collect them from a pharmacist. What are GPs for? If I have a disease, I would rather see a specialist. What patients want is to be seen quickly and at a time convenient to them.” Let me explain: they won’t get what they want or need from just any doctor. Patients want the same GP if they can get them, and preferably someone they know and trust. Most of our consultations are with such patients rather than those who rarely attend because they are healthy. The government just don’t get it, do they.
Most patients value continuity above speed of access. Most patients recognise that for them to have infinite access means that someone else has to have reduced access. I am in favour of infinite access but not when it means that your families’ access to you is reduced, and not when you are made to work to the point of exhaustion. Quality matters at least as much as quantity. Are you listening, ministers? You may think that voters want quantity, but we know that patients want quality.
What voters are getting at the moment is the bizarre “Policy by announcement”. What these announcements have in common is that they are rarely thought through and that there has been no attempt to engage the profession’s representatives. Is this how to run health policy, or anything else for that matter? Number 10’s plan is to listen only to those who will tell them what Number 10 wants to hear. They got advice that said they could reduce our pensions, particularly those already paid for by recent pensioners. Luckily for us, the High Court declared that the government broke the law and our pensioners will be fully compensated. Would it not have been a better saving of tax-payers’ money if they had not penalised our GP pensioners in the first place and been honest from the beginning?
The only way we are going to beat those who wish to see the back of us is to offer our patients the highest quality we can. GPs can always do better. The GPC is actively looking at how to achieve levels of proven and funded quality and we are working with the College to see how we can introduce Practice Accreditation - something else where we agree with ministers.
In dealing with a government that seems to be unable to stop trying to attack us, GPs must show firmness and politeness. We must encourage the government to introduce only evidence-based policy. We must keep our patients and the public on side and never do anything to harm patients or the services they receive. Our patient allies will only understand while we defend their NHS. We are there to deliver for them, and we will.
As the days darken and the threats become ever more real we have to remain steadfast. We must not rise to every insult, wherever the source. We may be berated by politicians but we must not be scared by them. It will not be lost on many that in this 60th year of the NHS, the inheritors of Nye Bevan seem to be busy dismantling it. Our patients deserve better than an untried hell for leather rush into the private unknown.
So, Conference, be sure about this. We will keep civilised pressure on those who, witting or not, are going to wreck what GPs have spent the last 60 years developing. We will work with patients – our most important allies – to prevent personalised, holistic, comprehensive, family-centred care from ending up as just another out-patients service. We mean business. If government want to work with us, then that will be fine. If they don’t, then we will show our patients what the politicians are trying to do to their services. So, what’s it to be government: peace and construction, or a never-ending fight to protect the NHS? I’m game for either.
Madam Chairman, I move that the Annual Report of GPC be received.
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