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Its the Workload, Stupid!!
Date: January 23, 2017
Its the Workload, Stupid!!

Following calls from a number of LMCs across England, including N Essex, GPC has announced a Special Conference of LMCs to be held on the 30th January 2016. The theme is “To decide what actions are needed to ensure GPs can deliver a safe and sustainable service.” It is more than 10 years since the last Special Conference and this is therefore a sign of just how desperate is the plight of general practice in England. There will be calls for Industrial Action (IA) and protest, similar to that currently being pursued by the Junior Doctors, but GPs are in an entirely different situation. 40% are salaried or locums who have no employer or are employed largely by other GPs, and the 60% contractor doctors have never shown a willingness to breach their contracts. IA is therefore a very difficult concept in general practice and its introduction would be unlikely to draw public support, without which it could not succeed.

There will also be calls for a “New contract” which will presumably solve all of our problems.

The Essex LMCs have sent the following motion to the conference:

That conference believes there will be no solution to the crisis facing general practice until the following actions are taken, and asks that GPC take responsibility for initiating this plan:

  1. a)  GPC leads a nationwide campaign to ensure that the workload of practices is limited to a level which is  considered to be safe for both patients and practitioners.
  2. b)  LMCs are supported to encourage and defend practices which follow safe practice guidance.
  3. c)  Practices are given the necessary tools and support to work only within their safe workload limits.
  4. d) NHS England commits to reducing local micro management and unnecessary bureaucracy and CCGs commission services which will address any surplus demand across the locality.
  5. e) Patient groups at a national and local level are given full information on this plan of action.

That conference believes there will be no solution to the crisis facing general practice until the following actions are taken, and asks that GPC take responsibility for initiating this plan:

  • GPC initiates a nationwide campaign to halt the rise in requests for medical letters from schools and educational establishments requiring proof of a student’s illness.
  • GPC initiates a nationwide campaign to engage with secondary care to highlight how patient safety is being compromised by increasing requests for GPs to review patients and investigations within less than 1 month after hospital discharge.
  • GPC insists that the DoH fund an occupational health service to issue Fitness to Work certificates.   Fitness to Work certificates should no longer be issued by GPs.
  • Travel insurance companies are reprimanded for routinely insisting that customers request GPs to approve and document “fitness to travel” statements in their medical records

That conference recommends that to better enable GPs to deliver a safe and sustainable service the frequency of appraisal is reduced to every 2-3 years instead of annually.

The point of the motion is that the problem in general practice is the intolerable workload and that the solution is largely already in our hands. There is no new contract which will save anyone from working themselves to exhaustion, early retirement, emigration etc. The profession needs to accept that doing the right thing and being the entry point to the NHS for most patients has created a job that in many cases cannot be done safely, and perhaps more importantly, is not attractive to new entrants.

There are dangers and problems with this approach and it will depend on practices across the land working in concert, and with the support of their patients.

The Co-commissioning agenda, where CCGs take on more responsibility for commissioning general practice, is gathering pace everywhere, largely due to the inability of NHS England to manage anything beyond microscopic and irritating contractual details. This tendency to stick to petty rules and the resultant inflexibility is driving practice managers mad.

In Essex we have one of our CCGs, Castle Point and Rochford, at level three or the most significant form of co-commissioning. They were supported by practices in doing so and appear to be making good progress. NHS England is increasingly pressurising CCGs to take on more responsibility, and to be honest the less NHS E does the better for the health service. Local managers are constantly hamstrung by mindless edicts from Leeds which have no regard for local relationships, circumstances or even common sense. NHS E acts as if all of England can be managed from a desk far away by people who appear never to have heard of Essex or its problems. It is impossible to believe these people care at all for the health in a County that is utterly foreign to them.

A recent example is the AUA DES data and payment shambles. We asked that practices be paid on account until the national process was corrected and were immediately told this was not allowed by Leeds.

There has recently been an announcement of £10 million across England to assist “Vulnerable” practices and we advise everyone with a possible claim for help to initially contact their CCG. Practices will be expected to fund 50% of any costs which I suspect will greatly reduce the impact of this scheme. In our view every practice in England is vulnerable, given the state of funding, recruitment and NHS management.

Essex has a “Success” regime but don’t ask me what exactly this means. It will probably be hospital focused due to the debts within our health system, and so continue to ignore the real needs of primary care. GP input into the Success planning appears to be slim but we have heard rumours that they plan to interfere with GP contracts. Any practice which is approached by friendly managers enticing them into wonderful new contractual arrangements is advised to contact the LMC, their accountant, their medical defence organisation and possibly their local psychiatric unit. There is no easy way to solve the problems in the NHS in Essex and anything that looks too good to be true is exactly that, it’s a lie.

One shining star which has appeared in Essex primary care is the introduction of EPIC, our new workforce development project. This is funded by Health Education England and hosted by EQUIP and we hope it will halt the decline in our workforce and allow every clinician to feel welcome, valued and with access to development opportunities.

Brian Balmer January 2016