THE BMA’s conference of Local Medical Committees on the 22/23rd May 2014 exposed a huge crisis in UK general practice.
This came out in the passionate speech of the new chairman of the BMA’s General Practitioners Committee (GPC) Dr Chaand Nagpaul.
He movingly described the impossible situation that GPs find themselves in. Their workload is overflowing with 40 million more patient attendances than five years ago, yet GP numbers have not increased and the proportion of NHS funding going to general practice has dropped from 10% a decade ago to less than 8% .
He summed up a quadruple whammy of workload crisis, lack of GPs and supporting staffs, inadequate premises and plummeting morale.Many motions on the agenda and open mic sessions dealt with these themes.
GPs described seeing up to 60 patients a day and doing home visits, phone calls, chasing results and lots of tickboxing and admin; some were working for 15 hours a day. The iniquity of the 10-minute patient consultation time was roundly condemned for not giving patients the care they needed.
Older GPs are retiring early and therefore more work falls on those left.
It is estimated that between 10 to 20,000 more GPs are needed. Recruitment of young GPs has slumped as medical students and junior doctors look at the heavy workload, the extended day, the paperwork, the stress and responsibility and the low morale of their older colleagues, who are vilified in the press despite all their efforts.
The simplistic ratings of practices by the CQC as ‘outstanding, good, requires improvement and inadequate’, were condemned and the CQC was described as a body that ‘strikes fear into every GP and is divisive and unfair’.
On top of this dearth of funding is the new threat of bankruptcy for 98 practices because of the withdrawal of Minimum Practice Income Guarantee ( MPIG ) money. This was the cause of the mass meeting in Tower Hamlets three weeks ago, as 17 practices realised they would not be able to survive without financial reparation for these cuts, as a consequence of which a march is to take place through the borough on Thursday June 5th.
Also, another £235m of provider medical services money is being removed from GP budgets by the government and diverted for ‘new initiatives’.
Speakers pointed out that GP pay has not risen beyond the 2003 level and last year resulted in a 0.28% ‘rise’ which was all absorbed by increasing costs. The pension changes and having to work to 68 years was also deplored.
The detrimental changes to the return and retainer scheme were opposed as well as the inappropriate use of zero-hours contracts for locums, with no payment for sick or holiday leave or redundancy.
There was a large section on education and training. There is no current scheme for updated GP premises, a big obstacle to improving care.
On the question of privatisation of the NHS, conference supported motion 10 stating that the reorganisation of the NHS in England, was and remains ‘a shambles’. It called on GPC ‘to work to protect GPs from the problems it has caused’.
Conference also voted to support motion 38 recognising that the ‘government has accelerated the process of privatisation as increasing numbers of NHS contracts since April 2013 are now delivered by private providers’ and called on GPC to ‘campaign for the NHS in England to be provided by the public sector’.
The worry of GPs at the loss of patient confidentiality was shown in the vote for all parts of motion 66 ‘believing that the introduction of care.data has been nothing short of disaster’. This asserted ‘that extraction of data should only take place with the explicit and informed consent of patients opting-in’ and that such data ‘should be pseudonymised or anonymised before it leaves the practice’ and only used for ‘health delivery and not sold for profit.’
Unfortunately, the government will always argue that the data will be used ‘to improve health delivery’ as its aim is that data will be used to assess patients’ clinical risk profile for insurance purposes.
The right wing also had its agenda at conference. This was to forward the government’s plan to privatise the NHS. The first steps of this plan require transforming CCGs into a different type of commissioning body, that would co-commission general practice itself, as well as hospital and community care, on the journey to becoming insurance structures.
The plan also requires that the ‘independent contractor model’ of most of general practices (GMS) would be abolished and practices would be merged into large federated units, or super-practices attractive to private sector management.
The plans also require patient co-charges for NHS clinical care, facilitated by the new Health Act.
Conference however voted out most of these motions. Conference voted against CCGs becoming co-commissioners (with NHSE Area teams ATs) of GP core contracts. Motion 11 said such this change would damage the relationship between CCGs and their member practices. Also the conflicts of interest would be unacceptable.
This refers to CCGs having the power to commission from one GP provider over another, thus raising the question as to whether GPs on the board favoured their own practices. The platform drew attention to the 9th May letter from Barbara Hakin, head of commissioning at NHSE on behalf of CE Simon Stevens, to all CCGs and ATs, inviting CCGs to become co-commissioners.
This spelled out that if they agreed, CCGs would have to participate in rationing resources, monitoring performance of member practices, apply contractual sanctions, decide on bringing in new providers including for-profit ones, and arbitrate on practice mergers.
The guest speaker at the Friday morning was Prof Chris Ham, who gave more airtime to the direction of travel of government policies, though it was dressed up as the King’s Fund ‘independent’ view. This 40 minute presentation entitled ‘Investment for Reform’ repeatedly stated that ‘Doing more of the same is not the answer’.
‘The Status quo is not an option. We need new models of care of extending community-based services’ based on ‘integrated health and social care teams available 24/7’.
He called for Networks, federations and super-partnerships in different parts of the country and networks would hold the contract, and pointed to US models such as ‘Care More’ and ‘Chen Med’. Another right-wing proposal buried in (ii) of Motion 20 was also scotched.
This part suggested that ‘conference believes that GPs will only provide routine planned care 8-8 seven days a week if resources are provided to the satisfaction of the profession.’
Conference instead voted for (i) which rejected ‘the concept of routine general practice care 8-8 seven days a week’. GP after GP had already outlined how overworked they are. Dr Williams from Wirral said, ‘If I work on Sunday, who will do the surgery on Monday?’
Motion 27 which called in (v) for ‘national charging for general practice services’ was also voted out. Dr McKeown from GPC, repeatedly proposed, ‘Fees for some services for some people’ as raising the value of general practice.
She said it was deceitful to say that healthcare is free at the point of delivery when we pay for it in taxes and national insurance. Dr Nagpaul commented that in all the countries with co-payments, patients are deterred from visiting the doctor.
He said, ‘The proposer said we pay through tax. We don’t tax illness. Charging would do that.’ Motion 35, calling for GPC to actively support the development of GP federations did get carried. (108 for &101 against).
The speaker from Northern Ireland (where the H&SC Act does not pertain), said it was not about super-surgeries and private companies there, and that it was led by the BMA. Opposing speakers pointed out that in England federations had a different meaning such as merging practices and overarching companies.
Dr Kinloch said, ‘We don’t need federations, as the King’s Fund proposes. With independent contractor status we have professional clinical freedom. In a large-scale federation there would be much more control and loss of independence. We would be pushed into salaried status. Virgin would be wringing their hands with glee at this debate.’
Another right-wing motion 50 was overwhelmingly defeated.
This stated ‘that the capitation funding formula for GP services is unfit for purpose and calls upon GPC to negotiate a payments-by-results (PBR) contract’.
Richard Vautrey of GPC advised that ‘It would be carving up existing money into widgets. PBR does not work for hospitals either. They are under-resourced. It increases micromanagement. They count widgets and manage the widgets. It would increase the risk of salami slicing.’
Overall the conference revealed a picture of a very devoted workforce of GPs enormously worried by the lack of new money for general practice, making their working lives a misery. Terms such as ‘tipping point’ ‘end game’ and ‘implosion’, revealed an intuition that the government is out to end British general practice as we know it.
But no alternative battle plan was proposed apart from the BMA campaign ‘Your GP cares’. This was launched on May 13th to publicise the importance of general practice, the desperate need for more funding and more GPs other staff and newer premises. The idea is to explain the situation to the public and put pressure on government. A video, a petition, letters to MPs, and posters are being produced.
A warning has to be given. Although the new chair and committee are aware of the situation, they expressed an acceptance of the requirement for £30bn of austerity cuts, and skated round the implications of the H&SC Act and S75 competition measures.
There was no clear clarion call against the strategic direction of travel of successive government towards co- commissioning of CCGs with NHSE, to fulfil the NHSE mandate to privatise all providers under the H&SC Act.
There was no clear call to fight off the type of federated primary community and social care organisations, with shared health and social care budgets, proposed by the King’s Fund.
These step-by-step ‘reforms’ are the route to an American-style insurance based healthcare system.
A leadership is needed which calls things by their real names and is prepared to defend the NHS as a public service from physical destruction by both Tory and labour governments, and reaches the logical conclusion. Capitalism in crisis is destroying all the public services to prop up the banks. It is capitalism that must go. A leadership is needed which will organise the defence of our original NHS structures: British general practice, district general hospitals and mental and community care, and our public sector workforce.
This requires coordinated industrial action with other unions to remove this government and replace it with a workers’ government and socialism, and a publicly owned economy, planned for people’s needs. Words alone will not save the NHS.