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27 March 2017

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‘Some practices are only just clinging on’

Dr Chaand Nagpaul is not afraid to voice his views on the topics that matter to general practice. As the chair of the British Medical Association (BMA)’s General Practice Committee (GPC), he has fought hard to highlight the crisis in general practice as well as to ensure the profession is well represented within the wider NHS. He worked on the details of NHS England’s GP Forward View which promised a £2.4bn investment in general practice and is set to see practices through a lot more changes in the coming year.

Why are so many GP practices struggling to cope at the moment?

Most practices are trying to cope with unmanageable workload and demand. We’ve seen approximately 70 million more patients per year than six years ago, and no increase in GP numbers. Many GP partners are leaving their practices because of this workload and either retiring early, or reducing their sessions or becoming locums – adding further strain to practices. Significant numbers of practices are running with vacancies, working intolerable hours, 12 or 14-hour days. They’re seeing up to 60 patients in a day on top of all the administration and home visits.

We have an older population – people are living longer, they are suffering from multiple medical problems and that requires more appointments and home visits.

Individual practices are suffering further funding cuts because of increasing expenses. They are employing more staff to cope with this extra work – nurses, admin staff and management staff. Many practices are incurring locum costs because they can’t recruit. A recent BMA survey showed that one practice in 10 believes it is financially unsustainable. I believe there were 201 practices last year that closed or merged. We also know there are much larger numbers of practices that are only just clinging on, struggling to survive with vacancies they can’t fill and working very, very long, exhausting days.

The government has reduced investment in the GMS contract. What are the implications?

The proportion of NHS money going to general practice has fallen year on year, and this is not sustainable. One in 10 practices says it will fold in the next year, and we are seeing practices close. This has dire consequences for the rest of the NHS. If you reduce general practice capacity by just 6%, because a practice closes or GPs leave, it would double the number of patients who would attend casualty instead. But general practice is at the heart of the Government’s Five-Year Forward View for the NHS. Without it, we can’t build the models of care the Government is proposing.

The GP Forward View
promises a £2.4bn investment in general practice, how will this help?

The Forward View has recognised that general practice is under considerable pressure. However, we don’t believe this money is enough. The Government must substantially increase the amount of money for the NHS – and give a larger proportion to general practice. But the Forward View is the first time in recent years that we have seen recognition of the pressures in general practice, and the desire to develop support. We are working with NHS England to ensure it is implemented in the best interests of everyday practices and patients. We must ensure that, unlike many previous government initiatives, this money reaches the front line without delay. It shouldn’t be lost in bureaucratic schemes or bidding processes that are not relating to direct patient care. General practice doesn’t have the capacity to waste time on bureaucratic bids for money.

How do you think the Forward View changes will unfold?

This depends, like so much in the NHS, on implementation. The Forward View is just beginning to move into an implementation phase. The first priority is to prevent practices from closing. This will be a test for NHS England – whether this scheme delivers results and is responsive to the needs of practices. Also I believe we need a very open debate about NHS funding. As there are austerity cuts across the NHS, we want the additional money to come from the Treasury explicitly committing to an increased level of funding.

The Government is trying to implement seven-day working across all professions. Would the BMA support seven-day working in general practice?

General practice already provides seven-day, 24-hour services. There is a general practice service every evening seven days a week, all weekends, and GP out-of-hours care throughout the night and over the weekends. The Government wants to develop routine appointments across the week, but we don’t have the capacity. We do believe that seven-day urgent care services must be improved. Patients should not need to go to casualty on a Sunday if their problem is appropriate for a GP, but we’ve found a disinvestment in out-of-hours services. We think the priority should be to invest in urgent care seven days a week, so that patients with any acute medical problem can see a GP instead of going to a hospital. NHS England has piloted seven-day services and found there is insufficient demand on a Sunday and Saturday afternoon, so it wouldn’t make sense to pay for GPs to sit in consulting rooms in empty waiting rooms. Also remember that those GPs would otherwise be providing urgent out-of-hours sessions. And many out-of-hours services are running with far too few GPs. We don’t want GPs to be diverted into seven-day clinics.

There’s a report saying that by next summer, waiting times for appointments will hit two weeks. What effect do you think this will have on general practice?

It’s very unfortunate that GP practices are sometimes blamed for reduced access. But longer waits are not because the receptionist is not being helpful, or the GP is not working hard enough. The problem is a gross mismatch between volumes of patients and the number of GPs. We must highlight this to the public, then I believe they will understand the waits. Another way to reduce demand is empowering patients towards self-management. There is scope for many patients with minor ailments to go to the pharmacy. Patients with chronic diseases can become expert patients. There are many situations where patients can be empowered to look at their own results and then see the GP at trigger moments – for instance those with diabetes and high blood pressure. We’ve promoted self-care as part of our Urgent Prescription. The Forward View also includes a commitment to that.

What are your views on multispecialty community provider (MCP) contracts?

We believe MCPs offer the opportunity for practices to work in a more integrated and collaborative way with community staff, and to reduce bureaucratic and organisational hurdles. However, there is no need for practices to give up their current contracts. The Government has, in the MCP contract, put forward three models, and we believe that two of them, which allow practices to retain their current contract, are the most sensible. There is a third model – the integrated MCP model – which would mean that a practice loses its national contract. We think that’s a mistake because that would result in a local GP service, not part of a national framework.