Clare Gerada's final keynote speech

Publication date: 03 October 2013

I’m a lucky person. I’ve been privileged to be Chair of this wonderful College for the last three years. It’s shot by in the blink of an eye. And though I’m about to step down as your Chair…It doesn’t feel like an ending to me it feels more like the start of an exciting new era for all of us.

When I became your Chair I offered Council five pledges, and a fantasy. My first pledge was around supporting GPs. General practice is a wonderful job – but a very demanding one, with its own particular stresses and strains.

And the recent changes in the NHS are making it even harder for many of us to keep our heads above water. It can sometimes feel as if we’re in the midst of an orchestrated campaign against us. We’re constantly under fire because we’re a soft target for politicians and the media.

They unfairly hold us responsible for anything that goes wrong in the NHS: for the failures in Emergency departments and social care, for the problems with bed-blocking. Berating us for not working out of hours though if it’s not us it’s certainly not the fairies doing the night shifts! You name it – our hard working profession is under fire – almost daily.

And yet, in truth, there is a hidden story. And that is right now general practice is in crisis! Our patients are ageing, and becoming more complex. We are expected to do more...for less.

General practice is being starved of resources and it’s getting worse.

We carry out 90% of all NHS contacts, for just 9% of the budget. That’s right: just 9% of the NHS budget. And that percentage share is falling!

What is the impact of this, on us GPs, and our patients?

We’ve commissioned two major opinion polls over the last few months to find out what things are really like in general practice and this is what GPs told us.

  • 85% of us think general practice is in crisis
  • nearly half think we can no longer guarantee safe patient care
  • the majority of us are conducting 40-60 patient consultations each day and working 11 hour days in the consulting room
  • and most of us predict that patients will have to wait longer for an appointment to see us –this is not good for our patients. 

Compared to 2008 -2009 in real terms General practice is £400 million worse off. This is the same as the amount of new money that the government is throwing in the direction of the emergency departments for a single year. The current situation is unsustainable!

But already there are signs that the drive to get the message out there is having an impact. Just the other day, Jeremy Hunt said on the Today programme that there needs to be more GPs.

Unfortunately, I think he may have got his sums wrong. He talked about having 2,000 more GPs. Actually we need to multiply this by five!

My second pledge was to promote the role of the generalist. And an achievement of my time in office was the Commission on Generalism.

Amanda Howe, and my successor Maureen Baker, played a key role in making this happen. The Commission’s report inspired a mantra that I’ve repeated throughout my time as Chair: GPs make the NHS safe, they make it value for money, and they make it accessible.

If general practice didn’t exist it would have to be invented. The RCGP 2022 gives a vision for general practice – the vision is clear: More GPs spending longer with their patients – that way we can make a difference.

My 3rd pledge was to support the next generation of GPs.

Since its launch in 2010, the First5 – our membership package for newly qualified GPs – has supported new GPs in the crucial first years of independent practice. We’ve expanded the number of Associates in Training on Council as it’s important to give new GPs a voice.

We must create leadership positions for the next generation. Our profession is changing fast and we must make sure new GPs are prepared for the challenges that lie ahead.

My fourth pledge was a commitment to address health inequalities by looking at ways of improving the health of the most marginalised patients we take care of like refugees, asylum seekers and drug users.

And we’re making progress. The issue of health inequalities is now one of our clinical priorities and we’re soon going to publish a major report to advise GPs on how to deliver excellent patient care for the homeless, gypsies and travellers, and sex workers.

My fifth and final pledge was to enhance GP training.

Everyone in this room who has trained as a GP knows that learning our trade is both an art and a science. Every patient we deal with is unique. The GP’s skill involves being able to translate evidence, and scientific knowledge, into the care of the individual patient in front of us.

And the longer we do the job, the more we understand the importance of finding the right balance between intuition and scientific rigour.

But achieving the perfect marriage of the science and the art of our discipline takes time. Three years’ training makes us competent, but we all know it takes longer to give us the confidence to manage risk and uncertainty. It takes time to time learn how to move beyond “rules-based medicine” to a mastery of the art of our profession.

So two years ago we sought, and got, permission to extend GP training to four years. An achievement I was very proud to have played a part in.

As well as my five pledges, there was my fantasy. I had a fantasy of tapping into Bill Gates’ £5 billion to spread general practice around the world. Sadly this didn’t materialise. But the vision remained undimmed, and we took the model of general practice to other countries, including India, China and South Africa.

The College has significantly expanded its role overseas – embarking on an ambitious journey of universal health care through general practice. It may be a slow journey, but it’s a noble and inspiring one – and I’m confident we’ll get there in the end!

And of course I couldn’t possibly report back on the progress we’ve made in the last three years without mentioning the move to our new premises in Euston Square.

Our old headquarters was like a gentlemen’s club. We needed to move to premises that reflect our image as a vibrant, forward-looking organisation with a growing membership of 49,000 and rising!

But one thing that came as a bolt out of the blue was the Health and Social Care Act which has dominated my time as Chair. Not only was it unexpected it was delivered by a government that had promised us no more top-down reorganisations!

When I became Chair I was advised to keep a low profile for six months, until I got the hang of the job. But things didn’t quite go to plan… Because the morning I became Chair I was catapulted into the eye of a media storm.

It was a rude awakening with me being plastered across the media – on the radio, the TV, and in the papers. I had dared to say the Health and Social Care Bill was a mistake. 

The Government insisted the changes would lead to better outcomes for patients. Only time will tell. But early evidence suggests what we feared chaos, confusion and an incoherent policy. In my view, in 10 years time, I predict, the NHS Act will be viewed as one of the historic misjudgements of all time.

Those early brushes with the media taught me that sticking your head above the parapet and saying what you think is a risky business. But it was worth it. Through the campaign, we forced the Government to announce an unprecedented pause in the legislative process, to row back on its emphasis on competition and to put the interest of patients back into the Act.

You won’t be surprised to hear that I don’t think the Act is perfect. But believe you me it’s a hell of lot better than it could have been! And that’s in no small part down to the principled support of the Members of this College! I’ve met some extraordinary people over the last three years.

I’ve hobnobbed with celebrities past and present…including Russell Brand. But one of the real highlights for me has always been the new member ceremonies. Every single time, I get this incredible feeling as I see the next generation coming through.

These new doctors give me confidence. They make me feel that whatever happens – whatever challenges we face – we’ve got this army of the most fantastic GPs you could ever wish for. It’s very reassuring to know our profession is in safe hands.

And talking of safe hands, this College is an extraordinary place to work. It’s full of the most talented, committed individuals I’ve ever had the honour – and pleasure – of working with.

They’ve stuck by me through thick and thin. They’ve been there for me in those dreaded moments where I might have said the wrong thing – or said too much. When the going’s been tough, they’ve rallied round me and supported me. And they continue to do that.

And darker moments have been brightened by you. The members. Thank you so much for all those little gifts. So many of them! The Yorkshire GP who dropped a bottle of wine off at the front desk with a note saying simply, “Thank you very much.”

Thanks to the person who sent me the Rescue Remedy – unfortunately, I discovered I couldn’t drink it during the day because it contained alcohol. Thanks to whoever sent me the plaster – I put it straight on my finger.

Thanks for all the books you sent me. Sorry I didn’t have time to read them all. I’ve had so many lovely letters and emails, tweets and texts. Even posters on Doctors Net UK have occasionally been kind.

What a tremendous honour, and delight, it’s been to be your Chair!

Going forward, we must be brave. The last three years have taught me an important lesson: when all around you appears to be in chaos – when you feel you’ve lost your way – when you don’t know what to do next… Stick to your values!

And we’ll need to stick to our values over the coming period as there are likely to involve changes that affect all of us. These changes won’t affect what we do – we’ll still be providing first contact care to patients in practices close to their homes.

But one of the things that must change is our relationship with our specialist colleagues. The way we work with them will change for the better – and the change will benefit us, them, and our patients.

The them-and-us divide – symbolised by the hospital entrance – will become a thing of the past. In future, we will be working together in one integrated system of care.

But in order to make this happen, we’re going to have to ask – and answer – some difficult questions about the way we do things. Our current health care system was set up to meet the needs of the population of post war Britain.

It was a time when the sick either died or got better. Nowadays we live longer. Nowadays there’s a growing number of patients with complex multiple morbidity – patients who wouldn’t have survived in the early years of the NHS.

We have to urgently address the twin scourges of our health system: Poor continuity of care and fragmented care.

Both made worse by the Health and Social Care Act. Both made worse by multiple providers, competition, and a market-driven health service.

And both made worse by perpetuating the divisions between hospital specialists and GPs – between providers and commissioners.

But we have it within our power to change things. I’m not talking about major structural reorganisation. Definitely not! Let’s put an end to restructuring – we’ve had far too many restructures in the last two decades.

Don Berwick summed it up perfectly when he wrote:

“In good faith and with sound logic, the leaders of the NHS and government have sorted and resorted local, regional, and national structures into a continual parade of new aggregates and agencies. Each change made sense, but the parade doesn’t make sense.

“It drains energy and confidence from the workforce and middle managers, who learn not to take risks, but rather to hold their breaths and wait for the next change. It is, I think, time to stop.”

The changes I envisage are not structural. First and foremost, we GPs are stewards of the NHS. But if we’re going to secure its future, we have to evolve with it. We must restore continuity of care - the tool of our trade.

We have to go forward together – and it will involve grasping some nettles! We will have to examine historic systems – like the independent contractor model – and ask ourselves: is this 1940s model – created as a pragmatic solution at the time – still fit for the 21st century?

We might also need to look at how we work together as small businesses, and ask the same question. I believe GP practices working in isolation have served their purpose well, but their time has passed.

Instead we need all providers of health and social care, within a geographically aligned area coming together and pooling resources.

The RCGP federations could then evolve into Integrated Care Cooperatives – provider organisations led by GPs. The aims of an Integrated Care Cooperative would be to reduce fragmentation of care, improve continuity, deliver care as close to home as possible, and deliver best value for money.

Primary, community, social and acute care budgets merged into one budget. In other words – integration.

Ironically, if the coalition hadn’t imposed its unwanted and unnecessary top-down reorganisation, this move towards integration would probably have happened anyway. There are many examples past and present to call on.

And now to my successor, Maureen.

She’s a formidably talented woman. She worked on the pandemic flu planning – which has become the model for the whole NHS – and the RCGP’s road map that serves as a template for GP 2022 and beyond.

We are very fortunate indeed to have her as our next Chair. She knows the College inside out. She has great intelligence, determination, and courage. Our College can only flourish with Maureen at the helm.

Which is important because we know it’s difficult times for us in our practices in our consulting rooms.

From our polls we know that many of you are exhausted. Demoralised even. We know that many of you fear for your future. But, hang in there! It will get better.

The College has started a campaign calling for Fair Funding For General Practice. We’re demanding that general practice gets at least 10% of the NHS budget, and at least 10,000 more GPs.

I’ve made the case to the Prime Minister, to the Deputy Prime Minister and to the Leader of the Opposition and any other politician who will listen to me!

And the College will continue to speak truth to power; tell it how it is – and drive home to those in High Office that for our patients’ sake general practice needs more resource!

So, despite the problems we face now, I believe the future is bright for general practice. The evidence amassed in the Commission on Generalism confirms what all of us already know to be true – the simplest and best way to get a better health service is to invest in primary care.

Let me end by saying that throughout my time as your Chair my aim has been to promote generalism
and the dedicated doctors who practise it – with every fibre of my being.

Thank you once again for giving me the opportunity to do this. I believe there are exciting times ahead for all of us.

Good luck – and thank you.


Further Information

RCGP Press office: 020 3188 7574/7575/7581
Out of hours: 0203 188 7659

Notes to editor

The Royal College of General Practitioners is a network of more than 50,000 family doctors working to improve care for patients. We work to encourage and maintain the highest standards of general medical practice and act as the voice of GPs on education, training, research and clinical standards.

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