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A united vision

31 July 2015

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General practice is facing some of its toughest struggles to date and now more than ever it is time for the profession to work together. Chaand Nagpaul gives a passionate insight into how he thinks this can be managed

There’s no denying Dr Chaand Nagpaul is on your side. As chair of the British Medical Association’s general practice committee (GPC) for two years he has carved out a reputation as a warrior fighting for the survival of general practice.
His undeniable support for general practice never wains and after 23 years as a GP he’s more than earned his stripes to speak on behalf of the profession, particularly after being awarded Commander of the Order of the British Empire (CBE) in this year’s Queen’s birthday honours for services to primary care.
But with general practice under increasing pressure where does Nagpaul see things going and how can it be sustained in the current climate?
The excessive workload is an increasing problem and one that secretary of state for health Jeremy Hunt also recognised in his recent ‘new deal’ speech. According to Nagpual a British Medical Association (BMA) survey, The Future of General Practice, of more than 15,000 GPs found that nine-out-of-ten feel that workload pressures are damaging the quality of care they can provide for patients. Nagpaul feels this problem is having a knock on effect with retention numbers. He says that as a result of this pressure, “one-in-three GPs in the BMA survey say they intend to retire in the next five years”.
This hasn’t gone unnoticed by junior doctors, which has created cause for concern regarding the future of general practice. “We also face a formidable challenge in GP recruitment, with bleak statistics showing no signs of any increase in GP trainee numbers.
“And with hundreds of unfilled GP training places nationally the truth is that when medical students and junior doctors visit a GP surgery as part of their training, far from the portrayal of lazy GPs working cushy office hours, they experience the total opposite of doctors overwhelmed from open ended demand, working longer hours than many hospital shifts, and taking work and worries home with them at night and weekends,” says Nagpaul.
It’s no surprise then that there is a struggle in recruiting junior doctors into general practice.
It’s understandable that Hunt’s latest speech hit a nerve with the profession, Nagpaul says: “It’s not possible to on the one hand identify that there is a real crisis of workforce and workload and then expect general practice to do seven days a week before you’ve corrected that.”
Patients have always been at the core of general practice and Nagpaul feels it is vital to involve them in their care. He has suggested that it is one way to relieve the pressure that general practice is facing.
He says: “There is considerable opportunity to improve self care, to empower patients with expert management, for those with chronic conditions. We know there is evidence that it can be both beneficial to patients and also reduce the number of appointments that patients need.”
Nagpaul, like so many, believes now is the time to look elsewhere to help ease the demand on GPs and general practice. “We certainly need other services to provide care for patients where appropriate; for example, there are a significant number of patients who could easily be adequately managed by going to their community pharmacy rather than having to see their GP. So there is certainly scope for that,” he says.
Managing demand can also be worked on by looking into overhauling NHS 111, as only 15% of NHS 111 calls are resulting in self-care compared to a previous level of 40%. This statistic is something Nagpaul feels can be lowered by turning NHS 111 into a clinically led triage system – as it was previously when it was NHS Direct and staffed by nurses.
As these challenges are affecting most of the country it is unsurprising that new ways of working have to be introduced in order for general practice to stay afloat – general practice needs to be stabilised. Mergers and federations are one way that Nagpaul sees general practice surviving but he recognises the need for practices to be on the same page.
He says: “I think the most important thing is that practices and GPs need to have a reason to work together. There is no point just having this mantra that we need to be herding practices together; there needs to be a strong reason, and the reasons for working together need to be owned by GPs themselves.”
But a united front is an approach that can work, and by joining forces “practices going through difficult times – like having difficulties recruiting, or losing management staff” can receive valuable advice from peers, as Nagpaul says.
With mergers and federations taking greater prominence in primary care the advantages aren’t lost on Nagpaul although it may be a hard truth for practice managers.
He says: “There is no reason why every practice needs to have a manager dealing with health and safety, information governance, infection control and education; these things can be provided at scale across practices and be more cost-effective, as well. So we certainly think that working together should be about supporting practices to provide good-quality general practice, which underpins everything else, because if you do not have a good foundation of general practice, it will have repercussions on the rest of the system.”
Most importantly Nagpaul recognises that if this is going to happen then the government needs to help by offering “some sort of organisational development fund”.
With such a varied mix of GPs it is a perfect opportunity to find ways of including them to benefit general practice.
He says: “Federations should be finding a way of including all of these [varied GP positions], and having a sense of common identity.”
Given the harsh climate that general practice is in, corporate companies such as Virgin Healthcare are becoming more prominent than ever before. Some even go so far as to say they provide better healthcare for patients, given that they can look after the business side of things while GPs can focus solely on patients. Nagpaul doesn’t agree with this concept. He believes the most efficient and effective way to deliver practice is to have GPs who provide the service being the same GPs who run the practice. He goes on to say: “We certainly believe that commercial models run by commercial companies loses that link between the GPs, the GP provider, and the local community.” The idea of companies owning general practice seems unsustainable to Nagpaul, as “you can’t rely on companies”.
He creates a clear argument as to why he feels general practice should be run by GPs. He says: “We have seen, over the years, companies run general practice services, and they have not found it profitable, they have walked away from contracts, because ultimately it is not a commercial setup.
“When GPs provide a service, they are not providing it from any sense of short-term profit gain.
“Most GPs’ practices have provided care for decades through very unprofitable times because of a commitment for providing services to local populations.
“So evidence has shown that large numbers of commercial contracts have come and gone, leaving patients destabilised and services having to be re-commissioned. We have seen this from the last administration when many of the primary care walk-in centres [known as the Darzi centres], that the previous Labour administration had introduced were run by commercial organisations and they came and went. So evidence shows that general practice is best served through the traditional GP contract, the General Medical Services (GMS) contract, contracted with GPs who are providers of that service.”
With members of the profession now, perhaps more than ever, having to work together to support the basic principles of general practice the role of the (GPC) has taken centre stage. The feedback that the GPC gets from GPs helps to shape the discussions it has with the government on matters that affect general practice. Nagpaul says that, “GPC is able to bring to the policy-makers, to the government, a picture of the reality, experience and aspirations of everyday GPs, and it is vital that this is taken into account in any policy development, otherwise as we have seen in the past, policies will fail because of lack of GP engagement”.
Looking to the future is imperative for general practice. But what can be done now to help workers on the ground?
Managing workload is one factor that can start to be looked at by practices. The BMA has produced a document, Quality First: Managing Workloads to Provide Safe Patient Care.
It is designed to help practices manage the demand that they are currently facing while putting patients first. Nagpaul recognises that “practices feel they are the backstop of everything that goes wrong in the rest of the NHS, and we need to be very careful because that is resulting in general practice bursting at the seams”.
With the frontline workers doing all they can to help keep general practice ticking along the very idea of a seven-day NHS in primary care is to some an unthinkable concept that will be unachievable in the current climate. It’s clear why Hunt’s ‘new deal’ speech took people by surprise. Nagpaul understandably wasn’t impressed with Hunt’s rhetoric. He says: “Unfortunately the new deal does not address these problems and there is very little detail or tangible proposals that will turn round these problems. The £10 million pounds for struggling practices is not enough. The pressures in general practice extends across the nation and is not confined to small pockets of under-doctored areas.”
Tackling the problem right now is Nagpaul’s priority.
Frustrated by Hunt requesting general practice to uphold its side of the deal he says: “I think the profession has felt that the idea of ‘our side of the deal’ is not today’s discussion. Todays’ discussion is about supporting general practice not expecting us to take on more. I don’t whether Jeremy Hunt meant that’s going to be your side of the bargain in a few year’s time, but certainly at the moment most GPs can give no more – they need to be supported.
“Ultimately it’s not a signed deal at the moment and I’m seeing this as an open discussion.
“We need to hold both Hunt and Simon Stevens [NHS England’s chief executive] to account because they have said there is burnout and they have said general practice is under-resourced. They have said they want to invest more in general. What the new deal didn’t say was how.
“We need to now go back and say ‘please deliver what you said you would’.”