Speech from the Chairman of the General Practitioners Committee
Dr John Chisholm
Tuesday 29 June 2004
The past year has again been momentous for general practice, with the greatest transformation through contractual change to the way in which general practitioners work within the National Health Service since the Service was founded in 1948.
The increase in funding for primary care through the implementation of the new GMS contract and its particular focus on the incentives in the Quality and Outcomes Framework will undoubtedly strengthen primary care and improve health outcomes.
But we do need a significant increase in the numbers of general practitioners in order to realise the contract’s full potential. That is why it was so short-sighted to withdraw funding from Deaneries in England in such a way as would endanger recruitment to vocational training for general practice. Although the English Minister for Health, John Hutton, acted with commendable speed to reverse that threat, there are still many worrying reports from Deaneries of threats to funding for and innovation in education.
The contract brings a huge increase in resources for primary care – a 33 per cent increase over three years. It brings a large rise in average GP incomes and a consequential increase in average pensions. It gives practices much greater flexibility to decide how services to patients should be organised. It allows almost all practices to transfer their out-of-hours responsibility to PCOs at a very affordable price – an opportunity the great majority of practices has chosen to take. And it introduces the Quality and Outcomes Framework, an evidence-based framework unique in the world in its comprehensiveness. Practices have responded magnificently to the Framework’s incentives. As a result, they will have the resources and the incomes they deserve. But even more importantly, health outcomes will improve and premature deaths will be prevented. A recently published paper suggests that in a 10000 population over five years, 54 cardiovascular events – such as heart attacks, strokes, heart failure and deaths from cardiovascular disease - would be prevented. That is the health gain GPs will achieve for their patients in their practices – an achievement to be proud of.
Whilst it is too early fully to assess the favourable effects of the new contract on morale, recruitment and retention, grassroots GPs are already seeing real benefits, including extra income and the out-of-hours opt-out. Despite some criticism, and the hard work inevitably associated with implementation, the new contract has delivered what doctors said they wanted: less work, the ability to say no to new work, better pay, better pensions, practice-level flexibility and increased investment in general practice.
However, the failure of strategic vision on the part of some Primary Care Organisations has been disappointing if sadly predictable. The contract gives enormous opportunities for PCOs to expand and develop primary care, to reform emergency care, to improve chronic disease management, to reconfigure services, to shift services from secondary to primary care, to take pressure off the hospital service, to reduce outpatient referrals and emergency admissions to hospital. The failure to grasp those opportunities has been unsatisfactory and unacceptable. There is a crucial three-way relationship – between PCOs, practices and LMCs. Where that relationship is cooperative and the PCO offers support and facilitation, the contract has been implemented successfully and its opportunities and strategic potential have been well understood. Where that relationship is failing, problems are almost inevitable.
One of the greatest causes of anger and disillusionment has been the failure of many PCOs to commission sufficient practice-based enhanced services. The timid short-termism of some PCOs, seeing the enhanced services expenditure floor more as a ceiling and suggesting some grossly inappropriate rebadging of pre-existing services, must be overcome, through the persuasive arguments of LMCs and practices, learning from examples of good practice elsewhere, performance-management via the Health Departments and Strategic Health Authorities and action by the national Implementation Coordination Groups.
I want to mention one other new contract issue. The GPC and the LMC Conference are concerned that the partial lifting of the ban on the sale of goodwill could increase the risk of fragmentation and a move from practice-based care, and that the costs of entry to general practice might increase and thus threaten recruitment to our specialty. Plurality of provision has its place, but only if that plurality is adding value rather than threatening the cost-effectiveness of the service, imperilling continuity and undermining patient satisfaction.
As you know, this is my last ARM as Chairman of the GPC. Chairing the GPC has been an enormous privilege, particularly at a time when my team and I have had such an opportunity to achieve major changes for our profession. I could not have done the job without fantastic support – from my negotiating team, from the GPC secretariat, from Local Medical Committees and GPs, from other crafts, the BMA, from other organisations, health care professions and individuals. I would like to thank all those who have given me that support, and above all my negotiating team and the GPC secretariat so ably led by Chris Finlan and Gail Norcliffe. Working with them has been not only a privilege and a pleasure, but enormous fun too – most of the time! And I want to thank you, members of this Representative Body, and the GPs of the UK, for the support I have received from you, and I hope you will join with me in thanking my colleagues and friends.
As this is my last Chairman’s speech, I want to conclude by emphasising beliefs and values, looking at the enduring features of general practice and considering the future.
The evidence is clear that countries whose health systems are more oriented to primary care achieve better levels of health, higher life expectancy, better health outcomes, higher satisfaction with health care among their populations, lower overall health care costs and lower medication use. Put simply, countries with strong primary care systems have healthier populations. Health systems based on effective primary care with highly trained generalist physicians practising in the community provide more cost-effective and clinically effective care than other health systems that are less oriented to primary care. Additionally, the more family physicians there are per head of population, the lower the hospitalisation rates and death rates.
The added value general practitioners bring to the effectiveness of health care is not always well understood. There are some who imagine that the job of a general practitioner can be divided into a multitude of components, each of which could be done as well by other professionals without GPs’ breadth and depth of training and ability. However, the risk-management, the toleration of uncertainty, the handling of unsorted problems, the holistic care, those roles that general practitioners fulfil so well, will not be delivered to best advantage if GPs only see people with complex problems and do not build up a longitudinal relationship with their patients.
All of us, at national and local level, in our discussions with the public, other health care professionals, doctors in other specialties, managers and politicians, need to be advocates for our specialty and what it can deliver to our patients. We are normally the point of first medical contact. We use resources efficiently through coordinating care, working with other professionals, managing the interface with other specialties and through our role as the patient’s advocate. We have a person-centred approach. We have a unique consultation process, founded on a relationship over time and on effective communication. We deliver longitudinal continuity of care. We manage acute and chronic problems simultaneously. We manage undifferentiated illness. We promote health and wellbeing. We are responsible for the health of the community. We deal with problems in their physical, psychological, social and cultural dimensions. We are general practitioners.
So I conclude by celebrating the magic, the mystery and the joy of general practice. Patients trust their GPs. GPs deserve that trust. They have enormous value to give to their patients – working in partnership with them to give them better health. They have much to be proud of. There is a wonderful future ahead for general practice.
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