Dr Hamish Meldrum's speech to the LMC Conference 2007
June 2007
Good Morning
My first task is to thank all those who have helped me, given me invaluable support and made my job as chairman, not only an easier one but a much more enjoyable one over the past year. My fellow doctors on the negotiating team, the GPC staff, colleagues throughout the BMA, have all worked incredibly hard during another difficult year for general practice and I hope you will join me in showing your warm appreciation for the wonderful work they do.
I would also like to thank the GPC, colleagues from LMCs and the wider profession. OK, not every comment, not every letter I get is full of praise and congratulations – if only - but this job would be infinitely more difficult without the warmth and friendship I so often receive, and I owe you, and them, all a deep debt of gratitude.
I mentioned a difficult year but it’s also a year of change and, almost certainly, further changes to come.
Difficult – perhaps an understatement - with the on-going dispute over pensions, difficult with the failure to reach agreement with NHS Employers, difficult with the zero award from the DDRB, difficult with an NHS that seems to stagger from one crisis to another, difficult with the continuing attacks on GPs.
Change with yet another reorganisation of PCTs and SHAs, change with the threat of more private providers, change with new governments in Scotland , Wales and Northern Ireland, change with a new Prime Minister, almost certainly a change in the Secretary of State for Health, possibly –I wish - even a change in health policy. And then of course, there are the changes taking place within the BMA itself.
Unpredictable times; uncertain times; unsettling times.
Let’s deal with the difficulties.
Pensions. As you know, we are taking the government to judicial review over this crucial matter both of principle and in terms of its very serious effects on a significant number of doctors. Principle, in that it’s a completely unacceptable breach of our agreement; serious effects, in respect of those doctors who have made retirement decisions on what was agreed and published.
I had hoped to be able to give you news of the progress of the JR today, but the wheels of justice grind exceedingly slowly. However, I can assure you that, while the government may break its promises, I will not break mine, to fight the pension issue with every weapon in our armoury.
I now turn to the failure to reach agreement with the NHSE on the 07/08 deal. I promised you last year that we would not accept another year where we agreed to take on new work without new resources. What was on offer – though I have to tell you it was a bit difficult at times to determine exactly what was on offer – was just that, a paltry pay increase but only in return for significant concessions on the QOF and the agreement to take on new areas of poorly-resourced work.
That was unacceptable, and the negotiating team, backed up by the full GPC gave it a resounding “No”.
On that basis we submitted evidence to the DDRB.
There were two crucial issues here – one, the government’s and the NHSE’s assertion that the DDRB no longer had any remit for GPs and the second, of course, the award itself. Well, we won on the first - the DDRB agreed they had a remit but the award – if one can dignify it with that name – was an insult.
It failed to recognise that an award is more than just about paying GPs. It’s about paying our staff, paying for our premises, resourcing the very nature of the work that we do – providing outstanding, high-quality care to the patients of the United Kingdom.
Of course I blame the DDRB but I chiefly blame the government for its late, inadequate, at best half-truthful, at worst downright untruthful evidence, which, yet again, made a mockery of the occasional supportive words we manage to squeeze from the lips of politicians.
Which brings me to the ongoing attacks on GPs.
As I said last year, I make no apologies for the pay increases that we successfully negotiated for GPs under the new contract, and no apologies that we are amongst the best paid in Europe – no apologies because you deserve it, as we provide the best care. And that’s not just me saying that. Last month, the Commonwealth Fund, a US equivalent of the King’s Fund, showed that the UK now tops the good-care list of English-speaking countries and that the UK system of general practice and, particularly, the QOF’s emphasis on high quality, chronic disease management, has helped push the UK to the top from the fourth place it occupied just a few years ago.
And that didn’t happen by accident. It happened as a result of the massive endeavours of GPs and their practice staff. It happened by GPs working harder than ever before. It happened despite a chorus of morale-sapping carping and criticism. It happened in the climate of a boom and bust, crisis-management-ridden NHS. It would be refreshing if the Daily Mail printed that for a change.
On access, which some say is our Achilles heel – you know, the old adage that general practice is a bit like bottled tomato ketchup – it’s very good but can be difficult to get at, – three years’ cumulative studies from the Improving Practice Questionnaire reports for the QOF, show that over 80% of patients rate their practices as excellent or very good and that satisfaction with appointment times and opening hours has improved over the past year. I fully expect that, when they get round to publishing it, even the government’s own and, to our minds, discredited Patient Experience Survey, will show just as good results, irrespective of how they try to spin it.
Eleven million pounds or more that could have been spent on patients just to demonstrate the bleeding obvious – what a waste, what a way to run a health service!
Talking of value, a face-to-face consultation with a GP still costs less than a call to NHS Direct, is about a fifth of the price of an A&E attendance and about a tenth of the price of a hospital outpatient appointment. And then of course, though for some reason that I can’t quite explain, this is not one of my most favoured statistics, I’m told it costs the NHS less for a patient to be registered with a GP practice for a year than it does to insure a year’s veterinary fees for a hamster!
Add to all this, the fact that doctors are still shown to be the most liked and trusted professionals. So, yet again, I salute the work, the effort, the dedication of UK general practice.
I also salute the work, the effort and the dedication of our public affairs division. I know they’ve had their critics. Whether it be advising the negotiating team, responding to ill-informed criticism, briefing journalists, politicians and opinion formers, arranging interviews both nationally and locally, producing positive GP stories, I can’t fault the support we’ve had from Brian Butler and his team. That, together with the work many of you have done locally, is something else we should be proud of and applaud, not carp or criticise.
I mentioned change. This conference has the subtitle of “Changing Times; Constant Values”. At the beginning of this year we completed yet another change in the structures of PCTs and SHAs in England. Another very expensive case of deck chairs and the Titanic?
Well, the initial signs don’t auger well. Last year’s record deficits now seemed to have miraculously turned into a net surplus.
Good news for the Secretary of State? Well, only temporarily. Irrespective of what this conference may vote later today, if I was Patricia, I wouldn’t be hanging on the end of the telephone, expecting good news when Gordon decides on his new cabinet.
Good news for doctors? No way! We only need to look at two or three key issues to confirm the answer to this.
Practice Based Commissioning. Apart from a few small oases of success, it’s a pretty barren desert out there. And don’t be fooled by the high uptake of the Towards PBC DES. Yes, a lot of practices have been interested but the reality has been a huge let down.
It’s a bit like buying a ticket to a celebrity party and finding that only Jade Goody has turned up.
Given the lack of support and the uncertainty about budgets and data accuracy, I don’t blame practices for being, at best, lukewarm and, at worst, not wanting to touch it with a barge pole.
Don’t misunderstand me, I would like to see PBC succeed, as I believe that, properly supported, properly funded, with a real commitment from the government and PCTs, it will be good for practices and good for patients but – and this is a huge “but” - unless there are significant practical improvements both nationally and locally, it just ain’t going to happen.
Then there have been the various attempts to save money, among them referral management schemes, the shameful raiding of training and education budgets, renegotiations of PMS contracts and increasing bureaucracy – particularly around the QOF.
Referral management schemes – at best they are a useful adjunct to commissioning and better case management, but at worst – and all too often – they are a very thinly disguised form of rationing that act as a Berlin Wall to patient choice.
“Choice” – there’s another example of a concept that’s fine in principle but which has been shamefully corrupted in practice. In fact the NHS Service Delivery and Organisation researchers stated:
“There is no evidence that giving patients greater choice will, in itself, improve the quality of their care. Some studies suggest that increasing choice may result in a deterioration in the quality and cost-effectiveness of services”
and,
“Most severely ill patients facing complex treatment options prefer decisions to made on their behalf by a well-informed and trusted health professional”
Not surprising that the government withdrew the paper from its website shortly after it was published!
We’ve seen the attacks on those practices who work under PMS contracts. Don’t get me wrong, as a PMS doctor, I have always wanted to see equity, where the same resources for the same services are made available to practices whether they be GMS, PMS or APMS. But this present witch hunt by certain PCTs is not only unfair to practices, it seriously risks damaging services to patients. So far, we have successfully fought off attempts at wholesale renegotiation of contracts by encouraging practices to stick together and to use the support of their LMCs. Of course we would like to see a national framework for a fair return to GMS but, until then, local unity is strength.
As for bureaucracy, particularly in relation to the QOF, I have to remind PCTs, including particularly those in the East Midlands SHA, that the GMS contract was agreed to be high trust, low bureaucracy. It’s completely ridiculous that we seem to have a bureaucratic system that really hacks off the vast majority of honest, hard-working GPs, treating them like undiscovered criminals and yet does nothing for those who really need help and support.
So all these changes have not been good news for the Secretary of State, not good news for doctors and they don’t seem to be good news for patients. And to add to the litany of problems we have the extreme measures that many PCTs have taken to try to save their own necks and Patricia’s job. Delayed operations and outpatient appointments, redundancies amongst staff, ward closures and the slashing of training budgets. No wonder so many doctors and patients alike have lost confidence in this government’s disastrous management of the NHS.
One might just about start to have a little bit of sympathy for Gordon Brown who, having made all this money available for the NHS, is just about to inherit a heap of NHS trouble. One might just start, but, on the other hand…..
And while I’m on the subject of our next prime minister I have another message for him.
A flagship policy for Gordon Brown’s government will be the maximum 18 week patient journey time from seeing their GP to getting the hospital treatment they need. The target date is the end of 2008. Last week, it was trumpeted that already 48% of patients get their treatment within the four-and-a-half-month’s timescale.
But if Gordon Brown wants his flagship to reach port he’s got to clear some of the obstacles in its way. Getting the other 52% of patients treated within 18 weeks is going to be much harder work – it’s always the easier ones first. All doctors want to see this become a reality for all patients. We want to see it work. But there’s wreckage around that could sink the ship – referral management centres that ration healthcare, choose and book that doesn’t work, practice based commissioning blocked at every turn, the junior doctor training fiasco, and, affecting everything, the grinding year-on-year cuts that prevent investing to improve. The message is clear, the doctors are prepared to crew your flagship Gordon – but only if you work with us, get the minesweepers out and remove the obstacles in our way.
I’m not one to make party political points but, as David Cameron pointed out the other week, “Gordon Brown should immediately open positive negotiations with GPs instead of attacking them. If the government is not happy with the contract they negotiated they should work with GPs rather than blame them for it.”
Not that I intend to do any re-negotiating on the basic tenets of the GP contract! As I emphasised last year, there’s no going back on the agreement on MPIG or on any change to contractual hours. No way, Mr Brown, or for that matter, no way, Mr Cameron!
I’ve concentrated on many of the English changes but, of course, many changes have taken place in the other three UK countries. With the election of new governments in Scotland and Wales and the new-found love-in between Paisley and Adams in Northern Ireland, the devolution pressures on the GP contract can only increase.
Whilst doing all we can to preserve the UK nature of the contract, we must strengthen our local structures, both for nations and within nations to cope with these pressures. At the heart of the latter are you, the LMCs, and I pledge to do all I can to support and assist you in the work that you do for GPs throughout the country.
I’ve talked a lot about the difficulties, the changes, yet this conference is also about the constant values that underpin our work.
Going round the country as I do, listening to GPs, reading their letters and their emails, I detect an unease, a dissatisfaction, often an anger. But I also detect a lack of self-confidence. Yes they’ve had a pay rise, yes, many of them have been relieved of the burden of out-of-hours responsibility, but for many of the older ones – my generation – they feel that the job of being a GP has changed – and not always for the better. Instead of the GP being the deliverer of care he or she has become more the manager and the organiser of care.
The end of general practice as we know it?
How often have we heard that phrase, but, for some, it does have a certain ring of truth and there’s almost a sense of loss, a sense of bereavement at the passing of what they felt were the good old days.
Whilst I have some sympathy, some empathy, I don’t share this view. Of course general practice has changed and continues to change and it’s true that in much of the government-inspired, meddling nonsense that is today’s NHS, so many of these changes are not changes for the better. The avalanches of unnecessary bureaucracy, the dogma-driven rush to privatise the NHS, the corruptive aspects of the internal market – no wonder there is anger and despair.
But the values that we hold dear, that are the essence of general practice, remain constant and unchanging.
The registered list, person-centred, holistic care, the ability to innovate, to be flexible, to deliver high-quality, family medicine to our patients - do not and must not change.
Governments may come and go, their initiatives change from one week to the next, new challenges may arise, new threats, but the values of general practice will survive and flourish.
For younger doctors, there are different concerns. Not only do we have the crisis, the shambles that is MMC and MTAS, the unfair and unjust cut in the GP registrars’ supplement, there is, for the first time in some years, the real prospect of GP unemployment or, at the very least, the inability to find partnerships.
There is a myth going around that younger colleagues don’t want to take on the responsibilities of running a practice, that they just want to see patients and nothing else. Whilst that may be true for some, at some stage in their careers, it’s certainly not true for all.
At this conference we will be calling for lots of people to do things for, or on behalf of, general practice. Today I want to call on you, the GPs of the UK, to do something for the future of general practice.
Nurture our young GPs, encourage our young GPs, stimulate our young GPs, value our young GPs, offer partnerships to our young GPs.
Don’t let the short-term financial pressures lead you to make decisions that will lead to the long-term detriment for general practice and bring about a self-fulfilling prophesy that will place the control of general practice into the hands of fewer and fewer people.
You don’t just owe it to our young colleagues, you owe it to yourselves and to the future of our profession.
These are changing times, difficult times, challenging times, not just for general practice but for the wider NHS and even for those who you elect to represent you. But this is not a time to dwell on the problems in the BMA or certainly my own, personal future.
Whatever role I am in, I can promise you this.
I will continue to fight for the under-pinning values of UK general practice.
I will continue to fight for a GPC and a BMA that fiercely and honestly represents the UK’s doctors
I will continue to fight for an NHS that retains the principles of fairness, equity, quality and universality.
I will continue to fight those who seek to destroy the NHS and the profession that has served and will continue to serve the patients of the UK.
I will continue to fight, with every fibre of my being, for a profession that I love and am proud to represent.
Thank you