Tuesday, September 25, 2007

Letter to MP

Peter Holden, GPC negotiator and jobbing GP, recently wrote to his MP regarding the current attack on GPs.

I was so impressed by his letter that I wrote my own MP (David Lepper(lab) in Brighton) and the MP (Norman Baker (lib.dem) in Lewes) in whose constituency my practice lies, using some of his information.

Below is a transcript of my letter.

Perhaps Peter and I can persuade more of you to do the same.

Norman Baker MP

23 East Street


East Sussex


Dear Mr Baker

I am a GP and am not one of your constituents, although my practice lies in Polegate. However, I am responsible for the health of approximately 2000 of your constituents. I am however sending a similar letter to David Lepper, the MP in whose constituency I live. I am also a member of the East Sussex Local Medical Committee, representing GPs.

I am heartily fed up with the current vogue in Government to blame GPs for the ills of the NHS. The recent media circus promulgated by the Prime Minister (among others) does nothing to actually alleviate the problems faced in Primary Care today. It serves only to cause a significant increase in the stresses of the job and consequently is directly responsible for the dramatic reduction in morale I see in my colleagues.

There has been a concerted government and probably No. 10 inspired campaign for several months about access to GPs, extended hours opening, and out of hours services. They are 3 different things but the government is trying to coalesce them. Part of the campaign has been to smear GPs by constant reference to their performance related pay earnings which are referred to as net earnings. Such net earnings are not take-home pay but net of practice expenses before tax, national insurance, sick pay insurance and surgery mortgage capital repayments.

At no stage during the current media onslaught against GPs has the government in the shape of No.10, the DoH or ministers contacted the General Practitioners Committee of the BMA - the body with whom the deal was done- about extended hours of service. They have received not one phone call, no letter, no email, no communication about extended hours. None of the negotiating team, nor the chairman of the GPC, Dr Laurence Buckman, has even had any informal approaches concerning extended hours from senior civil servants or ministers in their day to day business, including when paths have crossed. I have that on good authority from Dr Peter Holden of the GPC, one of the original negotiators (one of only 2 of the original team, including Dr Buckman; in contrast the NHSE/DoH team has none of the original team who engaged in negotiations).

Out of hours services (services outside of Mon-Fri 0800-1830)

The continuous and erroneous intimations that somehow GPs are responsible for the level of service provision in the out-of-hours period are nothing short of risible. It is widely ignored by Government spokesmen that responsibility for out-of-hours care has lain squarely with the PCTs since 2004, and not, as is so often stated, with the GPs. The NHSE, Treasury and DoH underestimated the cost and complexity of a service which GPs had provided at an uneconomic cost and a massive personal price since the inception of the NHS in 1948. For years the DoH officials had been denying the GPs assertions about the burden and the costs. For them to subsequently blame us for the inadequacies of a service which they are responsible for commissioning and managing is nonsense. In addition, there are frequent assertions that over 90% of GPs have opted out of providing out-of-hours cover. While in itself, that statement is true, the actuality of the situation is that many GPs still do work out-of-hours, but we have ceased to be the body responsible for the commissioning and running of the services, and so any inadequacies must be laid at the feet of the PCTs and the Department of Health. Their attempts to save money are what has led to the out-of-hours horror stories which occur from time to time, not the lack of GP involvement.

Extended hours is about the provision of NORMAL General Practice into the evenings and weekends. As I am sure you are fully aware modern General Practice requires receptionists, phlebotomists, Health Care assistants, practice nurses, district nurses, pathology services (such as blood testing), access to social services , X-ray facilities and the ability to discuss findings with a consultant. With the new contract we took on 52.5 hours of opening based on 37.5 hours of staffing and funded the difference from our "over-performance". PCTs have always been free to commission extended hours and some GPs may be prepared to provide it if commissioned at a commercially acceptable price. We are not prepared to simply be a "GP with a prescription pad" working alone, with patients having to return to complete the consultation, just so that the government can have a soundbite. I have asked my staff if they would (for pay obviously) be prepared to work extended hours and to a woman they said not at any price. In any event, in order not to breach the EWTD, some of us would have to take on and train yet more staff, something which would take considerable time and resource.

GPs are tired of the "banks and supermarkets opening argument". The longer banks and supermarkets open, the greater their profits. What is more, it takes at least 5 years to train any of my professional staff to work independently and up to a year for my non-professional staff. Shelf stackers and checkout operatives take a matter of weeks to train and the operation of the store does not require the continuous shop floor presence of the board of directors. The only people banks employ are sales people and money counters, who again take little real training. Indeed medicine, dentistry and veterinary medicine are the only professions where nothing can happen without the actual presence of the most highly skilled and trained individual member of the team working on the shop floor or immediately available to do so.


This is about the ease with which patients can make and obtain an appointment. A national survey costing £11 million has been undertaken recently and there is a satisfaction rate of 84% of patients with the current access arrangements. Analysis of this survey results in politically difficult messages. Most of the 16% of patients expressing dissatisfaction are registered with practices of a particular type, in particular geographical locations, serving a particular type of population, with services delivered by a doctor qualified from particular parts of the world. I know of many leading edge practices where they refuse to try to meet the 48 hour target (and forgo the resources) where the urgent and emergent are dealt with today but a routine appointment is 15-17 working days away.

Doctors have always struggled with their appointments systems. We are now on the 5th version since I joined the practice in 1999 and much of the problem concerns workforce resources and increasingly surgery space! The de facto moratorium on practice premises funding (unless you are in a Labour area LIFT scheme) means that we cannot increase our staffing as we are hot-desking already! We have always seen anyone with a clinical priority the same day and a clinical emergency on an immediate basis. Mr Blair's interference over the 48 hour access target (which we by and large meet) has meant that we cannot forward book significant chunks of the appointment book. I DO recognise the problems which working people, especially those who commute have in gaining access, but they are the very same people who do not want taxes to rise! Of course I could operate (and actually would take pride in) an 0700-2200 ROUTINE service 6 days per week (provided nobody was required to work compulsorily more than a 40 hour working week) but that is neither affordable nor cost effective. Even if we have the resources the staffing is impossible on current workforce Levels (GPs, never mind other staff).

The most recent straw contributing to the creaking in the spine of British General Practice has been the appointment of Ara Darzi to review General Practice. What does a tertiary world class surgeon know about general practice or primary care?

This crude attempt to blacken GPs for the political prize of 16 hours per day of routine general practice, even if does mean a return to paid slavery for GPs personally, is despicable. Irrespective of the financial facts, the government have conveniently forgotten the long term health gains already accruing from that performance related practice resource deal - the Quality and Outcomes framework. Doing this by means of fomenting public envy and disapproval of our earnings is beneath contempt and is hypocritical. Ministers in addition conveniently omit the facts that GPs still have to provide a service for a 40% longer working week than the norm. GPs still exceed the EWTD. 40% of GP income is performance related pay. GPs are stunning value for money. It is fascinating to note that the new accession states in the Baltic have adopted the British primary care system because of its cost effectiveness.

The new GP contract was negotiated and agreed with the knowledge, influence and intervention of No.10, HM Treasury as well as all 4 Departments of Health. It was further endorsed by the independent Doctors and Dentists Pay Review Body whose recommendation was not amended by the Prime Minister or the Chancellor at the time and they did not see fit to interfere with its findings! Gordon Brown and Tony Blair therefore had at least two opportunities to veto this deal if they felt that it had been too generous. The GP pay rise was deliberately substantial in return for substantial extra work and to correct the massive workforce crisis in General Practice. It was designed to correct 15 years of pay drift from repeated interference with DDRB reports. Remember that GPs were only required by Ken Clarke's contract to do 26 hours over 42 weeks per annum. You now get 52.5 hours of responsibility a week, with an actual average of 44. The fact that out of hours was priced by the independent DDRB as late as 1997 at only a few thousand pounds meant that the loss of it could only cost us a few thousand pounds.

You need to know that the massive relentless adverse and unfair media onslaught of the past few months against GPs has demoralised them hugely. Causing this much ill-feeling in GPs will damage the NHS because of the corrosive effect it has on morale. We have a massive GP retirement bulge looming in the next few years and the UK needs as many GPs as it can find. The government assertions border on lies and they are distorting the truth in such a manner that if I indulged in a likewise fashion in my practice I would be struck off.

I hope that this information helps to inform debate and I am happy to elaborate further, or direct you to other colleagues representing GPs if you wish. I do not wish to receive a reply from the Minister, as it will answer none of my points or concerns.

Yours sincerely

Russell Brown MB ChB

Go on. You know you want to.


TotallyBushed said...

Wow! Terrific stuff. Keep it going. Please. It's all so depressing that the author knows that this isn't a shot in the dark, it's a shot into a blackhole where nothing meaningful will ever return. It makes me simultaneously angry and dejected. They know this already. The media are just after copy. We need some kind of revolution. Anyone?

confused said...

What ordinary health consumers need, and appear to want, in the UK is access to a 24hr primary care service outside the hospital system as well has having a "GP" for ordinary times. This does not seem to be possible in the UK. Why not? Isn't this what the Brown govt is aiming for?

Russell Brown said...

Thanks for the comment, confused.

It wold be entirely possible to provide a service of that nature, but the costs would be prohibitive. Additionally, there just aren't enough GPs to run a service on that basis. Running it without GPs would be a nonsense: all that would happen is that patients would see a nurse or paramedic and be referred on to their own GP in hours or A&E or wherever. It is a fact that GPs training is in part about gate-keeping. With the best will in the world, emergency care practitioners are not in the same league as a GP when it comes to being able to diagnose and treat a multiplicity of problems.

It might I suppose be possible to alter the current model of provision of primary care, but at what cost? GPs working shifts in large centres further away from (most of) their patients, with littel or no continuity of care, less job satisfaction (and, trust me, that is very important if you want a service that works) and higher levels of staff turnover and sickness absence. That's ignoring the financial cost cost of providing the service.

GP has never been about a 24 hour service of routine care. Even access to a GP out-of-hours has only ever been on an urgent or emergency basis. I used to work Saturday mornings, and I was usually twiddling my thumbs, unless there was a flu epidemic going on.

Why do ordinary consumers need this, and where is the eveidence that they want it? The governments own £11m study showed that 86% of patients were happy with the current system. Now, accepted, 14% of 2 million-odd people surveyed is a large number, but of those unhappy with the service, a tiny fraction wanted Saturday opening for routine stuff.

What about my family? What about my quality of life? If my practice has to open longer hours, my income will drop precipitously as I will have to pay for other doctors to do those hours. I already work about 50 hours a week, I don't want to do any more. If my income drops precipitously, I may well have to consider my position and go and do something else. That is likely to be outside the NHS.

I'm 37. A significant minority of GPs are over 50. How many of them do you think will stay on if the government forces this on us?

hugh said...

superb letter. pity you didn't ak him to copy it to all MP's, who might then be better informed if no wiser.
Each time I read more of the government spin the happier I am that I retired last year.

Jobbing Doctor said...

Excellent. Wholeheartedly agree.

Prudential Life said...

Bril­liant! Great talk that was extremely insightful and very enter­taining. It’s given me loads to think about.