SLMC Conference – Dr Andrew Buist speech

Good morning conference.

I am sure like me you agree, it is good to be back in person, here at the Golden Jubilee. It’s been too long.

In many ways the last 3 years feel like a bad dream that we have just awoken from, only to discover that it was not a bad dream, and that things have got much worse than they were when last we met here in 2019. These are very difficult times for the NHS in Scotland and for general practice in particular

The Pandemic was challenging – but GP practices responded magnificently, demonstrating their flexibility and resourcefulness. Dealing with the constantly changing guidance, changing access requirements, shielding arrangements, CACs, infection control, Covid vaccination – we adapted, and we maintained our patient access and we ran our core service at the same time. 

Let me start with progress on the GMS contract and the MOU services. I am not happy, it has been a disappointing struggle, and I want to pay tribute to the huge amount of work at a local level from LMCs and GP subs.

Yes, we have successfully seen the transfer of vaccinations, including travel vaccines for most practices. But progress with the other Phase 1 MOU services has not gone so well due to the chronic problems of inadequate workforce supply and inadequate funding, resulting in most areas only having a partial delivery of some services.

Two of the services we prioritised in 2020, CTACs and Pharmacotherapy have had Regulations passed to ensure the transfer of the responsibility for these patient service to Health Boards in April 2023. Later this morning I will be seeking your support to ensure there is no legal backtracking on this commitment from SG for HBs.

Any reversal is totally unacceptable in my view and would in fact be grounds to consider there is no longer the political will in place to deliver the GMS contract. As for progress with Phase 2, it is on indefinite hold with no timescale to restart serious talks.

And let me deal with the £65M raid on PCIF and £5M from Sustainability. I know it hurt practices, many of you had made plans to recruit extra staff to increase capacity, so it felt desperate, but for me the greatest injury was not the monetary value, but rather the fact that Scottish Government have said publicly on many occasions that they value general practice, but their actions speak louder, and what these changes in agreement tells the profession …is no, …we do not value what you do as a GP.

In Scotland Core funding in general practice is an average £118 per person per year, a little under £10 per month. That is £20 a month less than it costs me to insure my dog. And while this level of funding might have been acceptable back in the early days of the NHS, it is no longer enough to meet the needs of our population today with our higher expectations, our drive for earlier interventions and most significantly of all, the increase in the number of older patients.

Our recent Vacancy survey showed that now 1/3 practices have a vacancy. The number of patients per GP is excessive, with each WTE GP now having 200 more patients than they did in 2009, because we do not have sufficient GPs.

The SG recognised this trend in 2017 with their 10-year plan to recruit 800 GPs, but as the SG Workforce survey figures have shown this week, once again, we are failing to increase the WTE number of GPs, in fact it fell by 3% to the lowest since surveys began in 2009. The number of WTE GPs for me is the litmus test of success with our contract. Our numbers are now lower that they were 10 years ago. We have made no progress. And is it any wonder? While we are training more doctors and GPs, we have done nothing to put the funding for these extra GPs into the core contract. It would be magical thinking to expect otherwise. I mean would a hospital trust really put a plan in place to increase their cardiologists and expect it to happen without the funding in place. Well, that is what has happened here. And so, often these newly trained GPs that Scottish taxpayers have funded, find employment outside of daytime general practice and may even seek work abroad. 

That is just not right.

And without the GP workforce growth we have a health service increasingly falling back on hospital care, so it is no wonder patients sometimes go to A&E, because that is where SG seems to have decided most investment needs to go. While our GP workforce has reduced by 5% since 2009, the number of WTE consultants has increased by 37%. Build the temple and they will come. And of course, ironically, perhaps inevitably, it is the GPs who get criticised for patients voting with their feet when in fact the problem lies with the decisions of governments and Health Boards. To avoid this continuing to be the reality we need a radical change of direction in our health policy in Scotland. We need to significantly increase the proportion of NHS spend in primary care, and we need to have limits on what can safely be expected of practice workload.

We continue to see unacceptable levels of reported abuse against GPs and their staff, and so I was grateful to the Cabinet Secretary for his support against this and for quashing the idea that we were not open or working extremely hard. But why did it need to be said? What political forces sought to put general practice down? And with what motive? I suggest it is about a plan to deconstruct general practice and thereby the NHS, a plan that emanates in parts of England. And having attended the England LMC conference last week I am convinced some in government seek to undermine GP to the point of destruction. Only the astonishing tenacity of practices in England to try to resist and survive keeps them going. But with a government set on breaking the model, their future must be uncertain.

Now I don’t believe our SG wants that to happen here, however the problem is that if our warnings go on being ignored, that is where we will end up too.  If we continue down this route, I believe we will see the end of the independent GP contractor model. The choice is stark, Scotland must be prepared to change direction now and properly support the IC model or we will lose it forever.

Our Wellbeing survey, was completed by over 1000 GPs. The most worrying finding was that only 18% of the GPs responding said they would recommend a career in general practice, 18%!  And I confess to you now, that last year I said yes, and this year changed to a maybe.  I say to the Scottish Government: how can you not see there is something seriously wrong going on here? If this statistic doesn’t tell you that the service is in a terminal decline – what will? My huge fear is that as a nation we are sleepwalking into the death of general practice as we have known it. The public will not like what replaces it, to say nothing of the potential impact on the public purse 

At the root of the problem is Excessive workload compared to our workforce capacity. Our surveys have shown it has become intolerable for over 80% of GPs. So, three weeks ago we launched our safe workload guidance for practices, and we encourage all practices to consider this in the context of their workload situation.

We seek a safe level of care for patients and safe working conditions for GPs and their staff. We say here and now it is no longer acceptable or safe to provide unlimited patient contacts. The average number of contacts per patient has significantly increased whereas the number of GPs has fallen. The SG must decide if they want good patient access and a safe quality service, where GPs have the time to properly assess and manage patients in the community and avoid them ending up in hospital. Alternatively, do they want a second-rate GP service, where GPs are so stretched that they have inadequate time to properly assess patients, with increased telephone contacts, reduced continuity, reduced job satisfaction, reduced retention, increased secondary care referrals, increased A/E attendances, loss of GPs, increased return of contracts, the emergence of under-doctored areas and rising health inequalities.

The choice is that stark.

Now there are a lot of pay disputes going on just now across the country, but our fight is not primarily about pay, although we do want that fairly maintained and this year’s award by SG will fall well short of that. But something needs done to give us fair and understandable pensions, not the current mess of Byzantine rules that even those running the scheme find hard to understand, with ludicrous tax penalties that are like something out of the Catch-22 novel, where hard work can be penalised to the point of a negative income from tax penalties, resulting in the destabilising loss of the very workforce we seek to retain.

The Chancellor of the Exchequer, Jeremy Hunt understood this only a few months ago when he chaired the Health select committee, and I would plead with him, to use that understanding and fix this craziness now that he is in a position to do something about it.

In conclusion conference,

We are witnessing the slow death of General practice in Scotland; it is being strangled by a severe lack of funding for an adequate workforce and drowned in a sea of workload. We no longer need service transformation; we now need a revolution in healthcare.

And to be fair it would be wrong to lay most of the blame for this situation at the Cabinet Secretary, Humza Yousaf, (and I would ask you please be respectful). The causes of the crisis that we are facing are mostly long-term and not of his making – a scapegoat will not help us, rather the crisis is the cumulative result of this Government and the ones before it going back 30 years or more.

In 2005 the Kerr report, Building a Health Service Fit for the Future, pointed the way to the kind of healthcare that our patients needed. We ignored the warnings then and continued to develop a hospital dependant-community light model of healthcare that does not meet the needs of the people of Scotland. Collectively we have let our patients down.

I believe we have reached a Tipping point.

We need a renewed vision for our NHS which guides us to a more positive future. So I fully support the call from BMA Scotland for a cross-party national debate with the public and key stakeholders on the future of healthcare in this country. And it needs to be Cross-party because otherwise it is too easy for the current opposition to take a swipe at the government, and because we need which-ever party is in power in the future to be fully signed up to the decisions we come to.

We need to build a realistic, achievable health and care vision of what we in Scotland should provide to our people; within the constraints of care provision that is free at the point of delivery. I have no doubt there are some very tough decisions to take there, but it is needed.

At the heart of this must be making working as a GP not just bearable again, but about getting the joy and professional satisfaction back into the job.

I desperately want to be able to recommend being a GP – as I am sure you all do too.

It is in the Government’s hands to reverse this bleak situation and restore the GP role to what it can and should be – and so, my challenge to them is for the sake the people of Scotland, to deliver the investment and agree the changes required to make this happen. 

Dr Andrew Buist is Chair of BMA Scotland’s GP Committee and was speaking at the Scottish Local Medical Committees Conference 2022

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