Thursday, 27 September 2007

This letter does the GPs' talking

The following letter from an esteemed GP to his MP reveals the truth behind the government's dishonest and cynical propaganda campaign against General Practitioners, the letter really does all the talking:


For your information and feel free to forward this to Andrew Lansley some facts about the GP pay deal and its "overperformance". (Okay I accept that I may be biased! But here are some facts, from one who actually knows the deal because I helped negotiate it!

I was one of the 8 doctors who negotiated the whole of that deal. Not only was I present in the room but asked the killer question of what happens if there was to be overperformance. Answer from Mike Farrar, the NHS team lead "The NHS Bank will bank roll it". We spent a WHOLE day telling them it would overperform. They checked back with ministers including The Treasury and the rest is history there are just 2 doctors left of that team of 8, myself plus Dr Laurence Buckman the GPC Chairman. There are NONE of the core NHSE team and NONE of the DoH core team still around and active on this work who negotiated the whole deal start to finish, so what the quality of advice to ministers is I don't know but from other interactions there is huge misunderstanding and misconception about the GPs first ever written contract!

Both sides adopted the principles of a "wise agreement" through principled negotiation backed by facts. All of my team and many of the NHS/DoH core team were all trained by the same negotiator training consultancy. There was almost no positional bargaining and little horse trading.

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 a 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. We have received not one phone call, no letter, no email no communication about extended hours. This could be the subject of difficult PQ if Mr Lansley wishes? None of the negotiating team, nor my chairman has even had any informal approaches concerning extended hours from senior civil servants nor ministers in our day to day business including when paths have crossed. All that we have had is megaphone defamation from a government which governs by assent from the baying crowd whipped up by spinmeisters feeding the chatterati via the media.

Out of hours services( Services outside M-F 0800-1830)

Out of Hours are the responsibility of PCTs and have been since 2004. 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. Quite how my practice went from 7 out of hours call per week average with 2 out of bed calls when I joined in 1985 to 60+ calls per week and out of bed 1-2 times per night (despite dropping obstetrics) in 2004 beats me. It was in fact the rise of consumerism coupled with a belief that there was 24 hour general practice. There never was 24 hour general practice and still isn't...just an out of hours service for emergencies and urgencies. What is more Saturday morning surgeries were never for routine matters as we did not have full services or staff available. Even now privately and also in a letter from DoH to one of my "constituents" the DoH concedes that GPs and their staff are entitled to proper work life balance.

The out of hours services horror stories occur because the PCTs wont commission sufficient cover and are using Eastern European doctors whose command of idiomatic English and knowledge of the system makes them slow. (I know what this means to patients, my own mother in law died because of the new arrangements when NYED failed). GPs in Derbyshire myself included work for the service (which is a good one) and actually there are fewer sessions than we are prepared to work as some of the work is being skill mixed to variable effect.

GPs have NOT stopped doing out of hours; they have ceased to be the body responsible for making that provision. GPs still work in significant numbers on the service and there are fewer doctor shifts than takers

Extended hours is about the provision of NORMAL General Practice into the evenings and weekends.

As you are fully aware modern General Practice requires receptionists,phlebotomists, Health Care assistants, practice nurses, district nurses, pathology and X-ray facilities (and the ability to discuss findings with a consultant), access to social services etc. Rough calculations indicate that to keep open my practice at HALF staffing for 2 evening per week to 9pm and for 3 hours on Saturday morning would cost in the order of £100K per annum and there would be no district nursing district nurses, pathology and X-ray facilities (and the ability to discuss findings with a consultant), or access to social services at that figure. 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 "overperformance". PCTs have always been free to commission extended hours and some GPs (my practice included) are 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 man/woman said not at any price. In any event in order not to breach the EWTD we would have to take on and train yet more staff something which would take considerable time and resource. As they pointed out the evening bus service is dire, they would have difficulty getting home and patients would have transport difficulties in getting to the surgery. (Buses, for example, after 1800 hours to Cromford are at 1900 and 2100 only and their are none to the outlying villages)

This is about the ease with which patients can make and obtain an appointment. A survey has been done and there is a satisfaction rate of 84% (The London Evening Standard [deliberately?] got it the wrong way around on Thursday. (Analysis of this survey results in politically difficult messages Most of the 16% are practices of a particular type, in a 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.

My optician [as opposed to the local spectacle supermarket] is booking 5 weeks ahead, my dentist 14 weeks, my solicitor 5 weeks, and my accountant 4 weeks. The Derbyshire Building Society wanted me to make an appointment to deposit a significant sum last week and yesterday PC World couldn't touch my computer for 3 weeks.

As you know from your formal visit to the practice in December 2005 (?) Doctors have always struggled with their appointments systems we are now on the 8th version since i joined the practice 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 and even if we have the resource the staffing is impossible on current workforce.

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 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 and 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 part of the team individual working on the shop floor or immediately available to do so.

The ultimate insult 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?

The crude attempt to blacken GPs for the political prize of 16 hours per day general practice even if does mean a return to paid slavery for GPs personally is despicable. To blame the GPs for the NHS deficit is deceit. Irrespective of the financial facts the government have conveniently forgotten the long term health gains already accruing from tha performance related practice resource deal - the Quality and Outcomes framework. Doing this by means of public envy and disapproval our earnings is beneath contempt and is hypocritical. ministers conveniently omit the facts in addition that GPS still have to provide a service for a 40% longer working week than the norm. GPs still exceed the EWTD. GPs only have to adjust their individual referral patterns by 1 referral per day to double waiting lists. 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 becasue 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 of responsibility 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.

Patrick, you need to know that the massive relentless adverse and unfair media onslaught of the past few months against GPs has demoralised them hugely. Cheesing off GP 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, they are distorting the truth in a manner which if I indulged in my practice I would be struck off.

I hope that this information helps to inform debate and I am happy to elaborate"

This letter explains pretty much everything there is to know about the GP out of hours debate and it does not make the government look very trustworthy or competent, in fact in makes the government look like a rather disorganised and dishonest bunch of bullies.

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