Days ahead of the 2015 RCGP conference in Glasgow, GPonline met primary care minister Alistair Burt to find out what he hopes to achieve in the role and where GPs fit into the government’s NHS plans. Read an edited transcript of the interview in full below.
GPonline: Your father was a GP. Could tell us what you learned from his experiences in the profession and how that might guide your approach as minister?
Alistair Burt (AB): ‘Yes, I am very lucky I am the son of a GP. My dad, who is still with us, practised in my home town of Bury from 1949 until he retired at 70. He had a practice in the poorer part of town. I saw from him enormous commitment. He started in a small practice which became a two-hander. His partner died of heart failure quite young, which of course was not uncommon in those days.
‘I saw a man who went out in the middle of night to see his patients, worked long hours; devoted to medicine. After he finished surgeries he was secretary of the local BMA, and became chairman of the family practitioner committee. So, he devoted his life to medicine and things associated with medicine.
‘And from him I got a sense of commitment to people. I liked his job, but because I couldn’t stand the sight of blood and wasn’t good at science, medicine was never for me.
‘In a sense, being a member of parliament has similarities to being GP. You cover a lot of people, you see a lot of people in different circumstances, so I feel, in a sense, that was passed down.
‘My father built the first group practices in the north west, in the sense that he brought a number of individual practices together under one roof, which gave them new consulting space and back office joined. Although they were separate practices, they worked together. So I saw the development of general practice in those years from the early sixties until I left Bury in 1997 when I stopped being the MP there.
‘So, my dad’s experience gave me a feel of general practice, a sense of the fulfilment that my dad got out of it, which is something I would love to see restored completely. Some doctors, I know, still have it. Others are very under pressure and there’s a sense that they have lost it. But it’s not given me a rosy view, in that the world is very different. Patients are different. Demand and expectations are different, and I was able to see evolution and change: see some of the things that needed to be done to ease the burden on practices like my my dad’s.
‘I saw the damage done with overnight work with little recovery time and things like that. So, there is always a need to change and adapt is something I learnt. And then as an MP over the best part of 30 years I’ve seen general practice continue to evolve during that time.
‘But my dad gave me, I think, a genuine love for what general practice could and should be, and that I certainly carry with me.’
GPonline: I know you’ve been meeting GPs since your appointment. What are the key messages you re hearing from those you meet?
AB: ‘It is very tough. I would be foolish to say anything other than that, both talking to GPs and reading the letters they send to their members of parliament, they are illustrating a life which is full of very serious challenges. It is busy. It seems relentless. And they worry where general practice is going. I also see a variety of responses to this.
‘I have been lucky enough to see some of the innovative practices that are working to do something new: a practice with a pharmacist in it. A practice that interviews by Skype. Practices that are looking to see how they can change their way of working to fit in with the community around them, recognising that people had different expectations in the past. These expectations must not become unreasonable.
‘There is a role for patients and patient participation groups here to make sure that what is expected of general practice is not unrealistic. But when I look at some of the innovations that doctors want to pursue, and I read about it, and I am aware of the Challenge Fund activity where, by March next year, we will have 18m patients covered by a seven-day-a-week service; then I see how people are prepared to meet the challenges, work for something different. And I much appreciate that.
‘But that it’s tough out there, yes I get that. I understand that.’
GPonline: You mentioned the Challenge Fund. GP/MP and health select committee chair Sarah Wollaston has recently repeated her criticism. She said with the current workforce crisis seven-day general practice by 2020 is ‘completely unrealistic’. How do you respond to that?
AB: ‘I take her challenge very seriously. She obviously knows what she is talking about and she’s a very good voice for medicine in the House. But in a sense, I have every reason to believe that we can do this, and I would like her to feel that we are on a track that will reassure her that this can be done.
‘And into that I would put the fact that we do have doctors who are working to try and do this. Seven-day-a-week working is not what some people sometimes fear it might be, or think it might be. It’s not about every surgery being open 8 to 8, seven days a week. It’s not about every doctor being constantly available over the course of the weekend or anything like that. It’s about working in partnership with others. It’s about providing GP services within an area through doctors grouping and working together and I think the evidence of the Challenge Fund will indicate that there is a need to be met.
‘We know from patients this is genuinely popular. People do feel that the availability of health seven days a week, both in hospitals and in GP practices, is something that is important to them. Expectations must be reasonable. And we must work hard in relation to expanding the workforce. Again we are very determined, as you and your readers are very aware, Jeremy Hunt wants to see 5,000 more doctors in general practice by 2020.
‘We want to augment that with the other allied professionals who are available, whether it is physician assistants, whether it is pharmacists, the other support services that can make a difference. We want to see what burdens can be taken off GPs. Because we know that there’s a percentage of the appointments that GPs have with patients at the moment where it is not necessary for a GP to handle it.
‘And we believe that a combination of efforts to recruit, retain, return more GPs will expand the workforce and, through the pilots we’re working, set us on this course for a seven-day-a week NHS which we think is manageable and reasonable. But I’m keen to reassure, it is not what sometimes people suggest it might be.’
GPonline: Regarding patient demand for a seven-day service. A number of Challenge Fund pilots have either reduced their extended hours, or have ended entirely. If evaluation of these pilots shows there’s not a big demand for routine services on Sunday, will the government accept that seven-day routine services is not right for everyone?
AB: ‘We will wait and see what the result of the challenge projects are. Evidence to date is that certainly there are places where this is working and where patients want it. There will be other places where there may not be a demand. I think the government should be entirely flexible. But the sense from patients is that those who cannot make routine appointments are looking for this opportunity, which is very different from the out-of-hours service, is one that is real. So let’s wait and see. We no more want to force patients into, “you must do this because the government said so”, than say “because it is not working in one or two areas, then there’s no demand”. Life is not like that.’
GPonline: So in terms of flexibility, in some areas where there is no demand for services on a Sunday ?
AB: ‘Then no one is going to be running them. But it has got to be tested out. Because people respond to what is there. And it does take time for people to recognise something new has come along. And to want to use it. In a sense that is what the pilots are all about. If the government had gone about this saying, “we are going to do this”, stroke of a pen, I think that would have been wrong. But it is not, so let’s test it out.’
GPonline: What happens when the funding for the Challenge Fund pilots runs out?
AB: ‘The very nature of pilots is they work out what demand might be, and then all pilots are absorbed by funding after that. As you know, Simon Stevens has set out his vision for the NHS: 8bn extra going in by 2020. And there will be increased investment in primary care.
‘That is part of the government’s overall investment in primary care, like the 1bn infrastructure fund, and everything else.
‘So, it’s not a question that when pilots end, that’s an end of it. There is an assumption that if pilots create a new sense of how people work, that is absorbed in the ebb and flow of funding as it comes on in the future.
‘We are quite used to pilots demonstrating that there is a need for a new form of working and then that becomes absorbed in the general costings of running what running the health service is all about.’
GPonline: But is there enough spare money around within NHS England or CCGs to fund these pilots?
AB: ‘The whole argument about funding the NHS is is very wide. The government is committed to support the chief executive’s view of where health should go over the next 5 years, and how it should be funded. And the government is committed to putting the funding in that Simon Stevens says is required. But in relation to general practice, you’ve got this billion pounds infrastructure fund, which will mean that many parts of the country will see improvements to facilities as a commitment to the future.
‘There is the extra money that’s going in to boost the training opportunities. We do recognise in relation to workforce there is a struggle. We want to see more young doctors opting to be GPs. So the 10m That Health Education England is working on to improve opportunities for doctors to come in, to retain more, return more, is really important.
‘And that’s part of the overall investment and, I should say, in terms of that and training, the support of RCGP has been very important. Their commitment to wanting to see more doctors coming to general practice and the statements they have made are genuinely welcome.
‘Overall I recognise the financial pressures on GPs and general practice. If we want to address concerns, that investment has got to be there. And that’s a priority for both Jeremy Hunt and myself.’
GPonline: The RCGP says 3,300 extra GPs would be required right now to meet current demand. Is that 5,000 target enough?
AB: ‘We think so. Again, as RCGP and others have told us, you can’t manufacture doctors out of nowhere. So there aren’t going to be 3,300 now. What there is, though, is a programme to reach the target – and it’s a genuine programme, it’s been worked through by NHS England, by Health Education England, and others. As indicated before: 5,000 more doctors in general practice and also 5,000 others. So a general expansion of the workforce in general practice by 2020.
‘Now, we’re trying to recognise that in order to meet demand there has got to be extra hands on deck. And that’s what we’re trying to produce, and we’ve got a pathway to do that. And there are plenty of people engaged on this who believe it’s doable.
‘What does it need? It needs the investment I’ve spoken about. It needs, and I know that doctors will find this a bit hard, maybe, but it does need encouragement from those in the profession: to say that this is something they want to do. And it is something they want people to follow into. Families have a tradition of going into medicine as your readers will know very well.
‘Medical schools could do more to say that being involved in general practice is as important as any other speciality they will orientate their students to. And they’ve got to really drive that. We’ve got a third round of recruiting going on at present. We’ve got evidence that making special facilities for people to return to general practice is attracting applicants.
‘We need the encouragement of everyone in the profession, of the professional bodies. As well as very clear statements from people like me.
‘A minister has both got to absorb the genuine concerns of the profession which I am trying to do, in responding to the colleagues who write to me, responding to the doctors who write to me, responding to the doctors I see. But at the same time, I do have to be positive about the future of the profession. And all I would ask is that when Jeremy and I make statements about the value of general practice, its role as the bedrock of medicine in British society, that we can say that and we can look to the innovations and the future while at the same time absorbing and recognising the concerns.’
‘It is not a zero-sum game. If we say the future of general practice is going to be something that practitioners want to be involved in, don’t feel is a burden, don’t want to encourage other people into. If we feel that there is a different future than that – at the same time we are saying that, we are not minimising the difficulties and challenges that we have.
‘That’s what I am out to do: to see doctors, to talk to them, to boost the good things that have been done, to recognise the difficulties, and to make a case for general practice.’
GPonline: But, a fifth of trainee place went unfilled this year. How can that be turned around?
AB: ‘We have an extra round going through to encourage more. There is determination to give those coming into general practice an extra year to follow a clinical speciality or interest of their choice, which will be funded. There are the efforts we are making with medical schools, the work Health Education England are doing. Absolutely, we are on to it. Both encouragement, investment and real attempts made to do to bring more trainees into general practice.’
GPonline: GPs have seen pay fall sharply in recent years while other doctors’ pay has risen slightly or been frozen, because the profession has faced soaring expenses that have not been recognised in pay awards. Do you accept that arresting the decline in GP income – down a quarter since 2005 – will have to be a fundamental part of reversing the workforce crisis in the profession?
‘Pay is important. It’s important for morale. I’m not surprised that doctors mention it. It’s very real and very human. I can t anticipate pay review, and I can t anticipate contract. And of course pay is only part of the experience of working, in terms of the burdens, the other things that the practice may do.
‘I think there is evidence we are trying to arrest all this, so as I say, I recognise that pay is part of it. It is only part of it, but it is an important one. And I think in terms of meeting concerns about how practices work and the general experience, we do have to recognise the pressure of expenses. And some of the expenses are very tough and outside a doctor’s control. So, it’s a bit of a package, but I don’t minimise the impact that pay has had, although general levels do compare with other parts of the general public and pay. But I don’t minimise for a second what it feels like if that is that is reducing.’
GPonline: Why isn t the decline in general practice s share of NHS funding being reversed, and how will it ever get it to the 11% recommended by RCGP?
AB: ‘I can’t anticipate the spending review. I have indicated that in the Forward View for the health service Simon Stevens recognises that putting extra money in requires investment right through the NHS. If we want to make general practice what we want it to be, and what doctors would want it to be, then investment is going to be necessary. In order to make sure that we can fulfil our commitments to have more done through the primary care system, in order to redress the balance between primary and secondary care, there will be investment, the NHS has made that very clear and the secretary of state has backed it.
‘I can’t say anything about percentages or balance, or anything else. We are going through the spending review, so I cannot say any more than that.’
GPonline: But, do you accept Simon Stevens’ point that general practice s share of funding must increase as a proportion of the NHS budget?
AB: ‘We need to make sure primary care can fulfil its obligations. Does this require investment? Of course it does.’