Editor's blog Saturday 9 October 2010: Extract from Professor Steve Field's valedictory RCGP speech

Extracts from Professor Steve Field's (edited) speech to the Royal College of General Practitioners follow below.

Key quotes:
"Unfortunately in the NHS, the commitment to ensuring that high quality care is provided for patients has been variable: Some Primary Care Organisations, such as Tower Hamlets, have tackled the poor performance of the tiny minority of GPs or practices that are not up to the required standard  ... others, however, have shirked their responsibilities, with some even halting their GP appraisal systems to save money a few years ago! If clinical governance and appraisal had been taken seriously by all PCTs then we wouldn’t have needed to spend so much time and effort on devising a system for revalidation"

...

"While Ara Darzi did a great job at putting quality at the heart of the NHS, and while the NHS Constitution laid out rights and responsibilities of for patients and staff, GPs were often left out of the work at regional level ... they did not deliver a single active GP as a medical director in any of the SHAs, nor had all PCTs had appointed GPs to their boards as medical directors".

...

"It’s a shame, but it was hardly surprising that the so-called “World Class Commissioning” failed in many parts of the country. What we got across England was a sprinkling of polyclinics and “Darzi” centres in places that we didn’t need them"

...

"We also saw more and more PFI hospitals built – giving us a flock of financial albatrosses for the next 30 years or so. We now have far too many hospitals in many parts of the country – and we are struggling to pay off the interest"

...

"GPs are being propelled to very centre of the NHS – and apparently being given the powers to lead it"

...

"We, the RCGP, have welcomed the direction of travel - it proposes what we have been calling for years - greater leadership and influence for GPs".

...

"there are some who think this is the worst thing ever to happen to the NHS and worry about the take-over of the NHS by big, for-profit American multinationals. There is a feeling that if GPs had been allowed to be more involved in leading PCTs, and in making commissioning decisions then we wouldn’t have needed the radical reform that is being proposed by the new Coalition Government. Most GPs, however, indicate that while they want to influence their local services they don’t actually want to be the ones doing the commissioning. They want to get on with providing generalist care for their patients."

...

"Our many younger members – many of whom make up the 43% of salaried GPs across the country – have said that they see opportunities in the White Paper to influence and to get involved, but are concerned that just like the GP contract that rewards partners and locks out some salaried doctors, that they may be left behind"

...

"We still have major concerns about the pace of change and we need to make sure that care and indeed access to care doesn’t deteriorate during the transition to this new system, which is a major risk at a time of such massive change.

"We believe that some of the work on integrated care models that have proven successful, for example in Torbay should continue despite the move to a more competitive system – in the end more integrated care around the needs of the patient will be the solution.

"If GPs are to be commissioners on a grand scale, we must have the resources, time, training and support to do this and make sure it's a success.

"There is not enough information available as yet for many GPs to decide whether the risks are worth taking – the question of what management allowance will be available is the most common question – and many feel that knowing more details will give them a better idea of whether it is possible to commission locally or whether much larger groups will be needed, bigger than current PCTs, in order to have the resource to commission effectively".

...

"it is possible for commissioning groups to start feeling their way forward under the wing of the local PCT. Perhaps that is what more should do, so that everyone can learn the lessons. It’s evolution that we need, but that can be rapid evolution! To be a success there needs to be enough GPs who are willing to lead commissioning groups, to take responsibility for the budgets, and who have the skills or access to the skills that are needed".

...
EDITED SPEECH TEXT

The College stands for high quality care, and we will continue to drive up standards for our patients wherever they live in the UK. They all deserve the highest quality GP care that we can provide.

Unfortunately in the NHS, the commitment to ensuring that high quality care is provided for patients has been variable: Some Primary Care Organisations, such as Tower Hamlets, have tackled the poor performance of the tiny minority of GPs or practices that are not up to the required standard and at the same time have actively supported improvements in care by supporting the professional development of GPs and the primary care teams. They have invested in improving care, and their outcomes have improved as a result.

Others, however, have shirked their responsibilities, with some even halting their GP appraisal systems to save money a few years ago! If clinical governance and appraisal had been taken seriously by all PCTs then we wouldn’t have needed to spend so much time and effort on devising a system for revalidation.

I believe that GPs working together in a Federation is the way forward, something which has been a central part of College policy since we published the Roadmap, three years ago.

l was really impressed by the Bolton Dashboard, when I went up to open their new  Federated community practice – it strikes me as being such a simple idea, I don’t understand why some of our colleagues have resisted sharing information with each other when it is so surely the way forward.

The day I spent in Bolton was inspiring: 7 practices – 7 “failing” practices – coming together as a federation, putting investment in buildings and investment in the development of GPs and their teams, all turned around by an inspirational GP leader Ann Talbot. The practices shared a triage system for patient calls, reducing the number of appointments and visits by opening up access via the telephone to patients. There is excellent pharmacist and nurse input to the triage scheme and the GPs seem really happy with the new system.

While I have seen some really exciting developments in primary care, it has become increasingly obvious to me that there are many vulnerable people who don’t even get access to poor care! I am thinking about the homeless, asylum seekers, travellers and sex-workers.  
Inclusion health seeks to drive improvements, mainly through system reform and clinical leadership, to ensure everyone gets the care they need, regardless of their needs or circumstances.

We need to ensure policies and programmes across health and the wider determinants of health consider the needs of those with multiple problems, and result in their equitable access to quality care.  

The research confirms that a small but significant group of the nation’s most vulnerable people continue to suffer from poor health outcomes across a range of indicators including self-reported health, life expectancy and morbidity.

Inclusion Health highlights that health inequalities persist, and that vulnerable groups experience a range of health needs, which can be exacerbated by social factors.

Furthermore, those with multiple complex needs often make chaotic and disproportionate use of health care services, and experience a range of barriers and issues relating to their access and quality of primary care. So often poor health drives wider social problems.  

But while I know there are some good models in Soho, Westminster and Leicester, generally the care is across the country is poor. For example: 31 of 125 PCTs operate an outreach team for homeless people; homeless people are estimated to consume 8 times more hospital inpatient services than the general population of similar age and make 5 times more A&E visits; 45% of street workers who had difficulty accessing their GP also reported fear of being judged by staff, whilst 37% were concerned that they were being ‘stared at’ by other patients.

The costs of failure are great, not only to the individual life chances of vulnerable clients, but also to the taxpayer, services and the communities who pick up the pieces.

We need to do more – society needs to do more – it may well be that with the opportunities that arise from GP-led commissioning we can do better for these vulnerable people.

I call on you all to think about how you might improve the care for you local vulnerable people – think Inclusion Health – see how you can reach out and provide better services. Reach out and make sure that you commission services to address their needs.
Four years ago, at the first annual conference, revalidation was the biggest issue on the horizon and I remember telling journalists that this would be my biggest focus and challenge for the next three years. How wrong I was!

Little could I have predicted that Lord Darzi's Next Stage Review of the NHS would dominate the first half of my Chairmanship as the RCGP went into action to demonstrate the true value of General Practice and defend the role of GPs in the NHS of the future.

While Ara Darzi did a great job at putting quality at the heart of the NHS, and while the NHS Constitution laid out rights and responsibilities of for patients and staff, GPs were often left out of the work at regional level. Further, despite being promised positions for GPs at all levels in the NHS, they did not deliver a single active GP as a medical director in any of the SHAs, nor had all PCTs had appointed GPs to their boards as medical directors before the election changed the landscape.

It’s a shame, but it was hardly surprising that the so-called “World Class Commissioning” failed in many parts of the country. What we got across England was a sprinkling of polyclinics and “Darzi” centres in places that we didn’t need them – what might seem good for Hackney is not necessarily the solution for rural Herefordshire. I have never understood why policies which are good for parts of London then get transplanted across England in such a top-down way.

The call for GPs to give up the care of children and hand it over to specialists reared its ugly head again – especially here in Yorkshire – and while we may have fought that one off, Ian Kennedy’s review of children’s services in England has put more coals in the fire. Some of what he said was very true. We really must have longer training for GPs, and of course it’s a disgrace that deaneries have still not guaranteed paediatric placements for our trainees.  
General Practice in the UK is family practice – a key part of our work is with children and their parents – the family – we must not give ground on this.

We also saw more and more PFI hospitals built – giving us a flock of financial albatrosses for the next 30 years or so. We now have far too many hospitals in many parts of the country – and we are struggling to pay off the interest. Alison Pollock stood here and warned us of this at an earlier conference; how right she was.

When I took on the role of Chairman, we were not punching hard enough politically; we all felt that general practice was under threat. I decided that what we needed to do was take the initiative, so: we worked closely with Laurence Buckman and our colleagues in the BMA; we developed a regional Darzi team to influence locally to add a GP voice at local, regional and national levels – and they did a great job.

We promoted the role of GPs and all primary care professionals – including the role of the school nurse on many occasions – we promoted the role of Federations of practices – we demanded more leadership positions for GPs on PCTs and SHAs; and we built closer relations with our academic colleagues to put evidence firmly behind what we said and did.

I got more involved in the media so that the College became the national and rational voice of general practice – speaking about quality, and intolerance of poor performance, calling for patients and the public to have more say and of course telling everyone about the key role of the generalist and primary care.

I worked constructively with politicians and civil servants, challenging when needed, providing constructive criticism and solutions and also praising when praise was due. I worked closely with the CMO during the flu epidemic, to provide information for GPs and for the public.

I have championed the rights of those who often don’t get the health care that they need: the homeless, sex workers, travellers, asylum seekers and most recently, veterans

I challenged injustice at the highest level – our successful campaign with other organisations to stop children of asylum seekers being taken from their home in the dark of night and locked up in detention centres led to a change in government policy.

And of course, I have not forgotten that we are a UK College. I continue to work closely with our 3 Country Chairs to ensure that they are supported when needed without me getting in the way of their work with the devolved administrations.

We seemed to be getting somewhere – Then there was a General Election! How times change, and here, once more we are on the brink of yet more change. However, this time, GPs are being propelled to very centre of the NHS – and apparently being given the powers to lead it.

I’m sure the White Paper will be the subject of much debate and discussion over the next three days – though, with such a packed programme, I’m sure you’ll be spoilt for choice.

While The White Paper applies to England only, we felt it was important to seek the views of our entire 42,000 Membership in the UK and internationally. We received a terrific response and I’d like to thank all of you who took the time to give us your views.

The response went into the Department of Health in England on Tuesday and I’d particularly like to thank our Honorary Secretary Amanda Howe for all the hours and dedication she and her team have put into delivering such a comprehensive and constructive response.

I think we have made a realistic and appropriate response for a profession that has the interests of our patients at its heart.

We, the RCGP, have welcomed the direction of travel - it proposes what we have been calling for years - greater leadership and influence for GPs.

It also calls for much more patient and public involvement: ‘No decision about me without me’. This is a concept that has been welcomed by our members, and one that places patients at the centre of primary care. This is something we have espoused since we were formed in the 1950s; it’s in the DNA of the College and we demonstrate it in our curriculum, in our MRCGP and in our iMAP assessments.

Where we have reservations, we have offered our solutions and suggestions. We have put them in our response, and we have spoken about them at meetings with the DH and with Ministers.  I have spoken with many GPs at meetings around the country, listened to a very lively debate at our Council and read the many responses of our members and fellows.

While there many GPs who are really enthusiastic about the opportunities offered in the White Paper – and you find more enthusiasts at meetings than those who write in to us – there are some who think this is the worst thing ever to happen to the NHS and worry about the take-over of the NHS by big, for-profit American multinationals.

There is a feeling that if GPs had been allowed to be more involved in leading PCTs, and in making commissioning decisions then we wouldn’t have needed the radical reform that is being proposed by the new Coalition Government.

Most GPs, however, indicate that while they want to influence their local services they don’t actually want to be the ones doing the commissioning. They want to get on with providing generalist care for their patients.

Members, GPs from Scotland, Wales and Northern Ireland spoke at Council and expressed concerns about the English system moving further away from theirs with possible impact our UK training programmes and standards

I have listened to the debate with interest – remembering only too well the debates we had about the Darzi reforms.

I conclude that while this is a massive reform of the NHS, and it is not without its risks, there are major opportunities for GPs to lead the NHS in England, to design care better tailored for our patients rather than being told what to do from on high or at least from London!

For example: we won’t have any more Darzi centres imposed on us from above; we will have much more of a say on what local services look like, leading to a much more joined up service, better access to diagnostics in the community, better out-of-hours and urgent care, more care in the community, more innovation, and a service more responsive to the needs of our patients.

I believe the White Paper will lead to improvements in public health; and GPs have an important role to play here too, working with Local Government to join up health and social care to provide a much more personalised system for our patients with long term conditions with a focus on prevention.

We can build on our Federated model and the key work that we have been doing with the RCP, RCPsych and RCPCH: ‘Teams without Walls’ to produce much more integrated services for our patients working with our colleagues in secondary care.

We must of course work with our specialist colleagues, health care professionals and, of course, managers – and there are many excellent managers in PCTs across the country – in commissioning: Collaborative commissioning – designing the care for our patients, with our patients.

Our many younger members – many of whom make up the 43% of salaried GPs across the country – have said that they see opportunities in the White Paper to influence and to get involved, but are concerned that just like the GP contract that rewards partners and locks out some salaried doctors, that they may be left behind. We must promote their cause – First 5 is just the start.

The White Paper might well mean that we look at alternative providers – but that doesn’t mean it has to be for-profit organisations, we already commission from outside what many call the ‘NHS family’ – even in mental health. Think of Turning Point, that provide excellent substance misuse services in many areas; or think of the role of hospices and charities like Macmillan who might help us look after more people at home – we all know that too many people die in hospital when they would rather die at home – here is our chance to change things for the better.

For me this is less about GP-led commissioning and more about greater involvement of patients and the public in the design of their NHS services. Let’s see what they think – what they want – what they need – we don’t always have all of the answers.
Implementation is of course the key: We still have major concerns about the pace of change and we need to make sure that care and indeed access to care doesn’t deteriorate during the transition to this new system, which is a major risk at a time of such massive change.

We believe that some of the work on integrated care models that have proven successful, for example in Torbay should continue despite the move to a more competitive system – in the end more integrated care around the needs of the patient will be the solution.

If GPs are to be commissioners on a grand scale, we must have the resources, time, training and support to do this and make sure it's a success.

There is not enough information available as yet for many GPs to decide whether the risks are worth taking – the question of what management allowance will be available is the most common question – and many feel that knowing more details will give them a better idea of whether it is possible to commission locally or whether much larger groups will be needed, bigger than current PCTs, in order to have the resource to commission effectively.

While some wait for more detail, some move forward with pace, like in Cambridge – the first out of the trap – and they demonstrate that it is possible for commissioning groups to start feeling their way forward under the wing of the local PCT. Perhaps that is what more should do so that everyone can learn the lessons. It’s evolution that we need, but that can be rapid evolution! To be a success there needs to be enough GPs who are willing to lead commissioning groups, to take responsibility for the budgets, and who have the skills or access to the skills that are needed.

There is a key role for the College in helping GPs acquire the skills that they will need, and I know that Clare Gerada is working on ideas with the NHS Institute and others, and that she will be sharing them with you during this conference. We need to work with the NHS Confederation, with the Kings Fund, with the NAPC, the NHS Alliance and others. We all have something to offer – but this is a great opportunity for the College to lead – to support GPs across the country and to deliver a GP led, patient centred service.

After all if we don’t do it, who will?