Local medical committee conferenceBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7201.61 (Published 03 July 1999) Cite this as: BMJ 1999;319:61
News p 12
NHS Direct should be properly piloted
Representatives of the 35 000 GPs in the United Kingdom have strongly criticised the NHS Direct advice centres run by triage nurses, although last week's conference of local medical committees stopped short of calling for the project to be abandoned.
The chairman of the General Practitioners Committee (GPC) told the meeting that in England NHS Direct was being rolled out “like there's no tomorrow, well before the evaluation has revealed any convincing evidence of more appropriate use of the NHS, the lack of harm to general practice, improved health outcomes, and value for money.”
The conference deplored the government's failure to evaluate the pilots properly and called for consultation with the profession before the scheme was extended. Doctors want clarification of where NHS Direct's responsibilities end and GPs' begin. They believe that the scheme will damage the role of the primary care team and the GP as gatekeeper and will increase patient demand and GP workload.
Dr John Higgie (Somerset) provides medical advice to NHS Direct in south west England and said that one of the reasons NHS Direct was set up was in answer to doctors' pleas for help with dealing with trivia. But he failed to persuade the meeting that it should support the potential of NHS Direct as an advice service to save time and direct patients to appropriate care.
Time will not be saved
Most speakers disagreed with him. Dr John Machen (East and North Hertfordshire) said that a survey in one area showed that the service led to an increase in the number of patients demanding same day GP consultations. Whose time was being saved? The computer generated triage took as long as 40 minutes to come to a conclusion. “I hope they can cope over the millennium,” he said. In his practice 54% of the callers were referred back to the practice.
“NHS Direct cannot save our time,” Dr John Fitton (Northamptonshire) said. Many of the callers who were told to contact their GP had never thought of doing so.
The meeting agreed with him, but he was criticised for being too negative. Dr Stephen Earwicker (Nottingham) pointed out that at present no one knew if NHS Direct would be a threat, but it might be the mechanism for ensuring proper use of services. It wasn't going to be abandoned, and he preferred to see NHS Direct run with GPs firmly in the driving seat.
Walk in centres will fuel demand
Dr Barbara West (Glasgow) persuaded the meeting to endorse a composite motion, which said that walk in primary care centres would fuel demand, would damage the coordinated treatment of patients, and would divert scarce resources away from existing GP services. It resolved that the centres should be expanded only after proper evaluation and with the agreement of the profession. “When the government finds new money why does it put it towards an ill conceived idea rather than to general practice?” Dr West asked.
“Put the government in the dock, not your negotiating team,” Dr John Chisholm urged the conference
Dr Jill Bartlett (West Hertfordshire) compared the use of walk in centres with car maintenance. “How many of us would drop into any old garage rather than go to the garage and the mechanic that we know?” Only a fool would do that regularly. Walk in centres were ill thought out as a quick fix at the expense of previously tried and tested methods of care.
The GPC chairman believed that the government should be more concerned about people waiting four years for hospital treatment rather than a few days to see a GP. “Walk in centres must not undermine general practice and resources must not be diverted.” They would encourage patients to consult when they need not do so.
GPC chairman survives vote of no confidence
A vote of no confidence in Dr John Chisholm and the other GPC negotiators was overwhelmingly defeated, and Dr Chisholm was given a standing ovation after he gave a forceful defence of their actions.
The censure came from the Wessex Division of the BMA for the negotiators' failure to achieve adequate safeguards for GPs over the development of primary care groups (PCGs). Dr Douglas McLeod said that the team had forgotten that their primary role was to protect the interest of all GPs not to seek a role in the redevelopment of the health service. The government and health authorities would now hold PCGs to account. The negotiators had allowed the government to inadequately fund the service. Dr McLeod said that it was a mistake not to hold a ballot and he called on the team to resign and be replaced by people who were prepared to undertake any action that was necessary.
He was supported by only two speakers. Dr David Roberts (GPC) said that there was more to the issue than PCGs. “It is not so much a case of no confidence, rather of seriously diminishing confidence.”
The secretary of the Inner London Local Medical Committees, Dr Tony Stanton, said that he felt disbelief, shame, and anger when he saw the motion. Only last year the conference had overwhelmingly endorsed the package of measures achieved by the negotiators on PCGs. “PCGs have been developed because that is what the government wishes to see happen.”
“This is really a motion of no confidence in the GPC and the conference,” Dr Chisholm insisted, because the conference had approved the package in 1998. The government had been elected to abolish fundholding; it had built on this and the GPC had run with the agenda. “Otherwise we really would have been under threat. And we have made the best of the agenda.” The GMC chairman said, “We would not do this job if we did not care about patients and the future of general practice. Put the government in the dock, not your negotiating team.”
Revalidation must be profession led
GPs want revalidation to be led by doctors and not be part of the functions of health authorities or primary care groups in England and their equivalent in other parts of the United Kingdom. Medicopolitical digest
The conference called for the process to be linked to standards of clinical competence, to be fully funded from new central government funds, and to occur in protected time. Dr Stephen Linton (North and Mid Hampshire) said, “Revalidation must not be another way of cutting the costs of running the NHS. It must not be another means of rationing.” He also called for no exemption for training practices. “All doctors must be treated the same or the system will lose the confidence of the profession.”
Dr Peter Trenchyard (Northamptonshire) asked the conference to think about the implications. “Will it prevent further scandals? Will it be good value or a good use of our time?” He was worried that if doctors were paid for the time spent on revalidation they would be controlled by those who paid, and he suggested that clinical governance and revalidation could be integrated.
In his opening address the GPC chairman said that the government and the General Medical Council must not forget that quality had a price, and supporting the motion Dr John Chisholm said that revalidation must be introduced only after full consultation with the profession; the GMC had agreed.
Public campaign on general practice needed
GPs' representatives have called for a public campaign on the value of general practice and a rapid response unit to rebut the denigration of the profession by the government and the media.
Dr Sunil Bhanot (North and Mid Hampshire) believed that most doctors were doing an amazing job, caring for their patients with compassion and sensitivity. At the same time the government was blaming doctors for the ills of the NHS. It was insulting to compare medicine with 24 hour banking. “We must communicate what is good about general practice.” He wanted the GPC to mount a bigger, better, and slicker campaign than had ever been mounted before. “It is time to send in the troops. Go back to your constituencies and prepare for battle,” Dr Bhanot urged.
There was also a need to educate the wider health population, according to Dr Ann Smith (West Sussex). An executive director on her health authority was unaware that GPs were independent contractors or that they dealt with 90% of patient contacts.
Dr Simon Fradd, a GPC negotiator, assured the conference that the GPC did use the media to improve the perception of general practice, but he opposed the idea of an advertising campaign because of the expense. But he did accept that the approach could be strengthened. The forthcoming consultation document and the conference in March 2000 would be at the core of a massive publicity campaign.
Nearly 500 representatives attended the conference
Identity of accused doctors cannot be protected
A plea for legislation to ensure that GPs accused of serious professional misconduct had their identity protected until or unless found guilty was defeated.
Dr David Hughes (North Staffordshire) referred to the pressure that doctors faced when accused and reported to the General Medical Council. If their identity was protected the distress would be reduced. Some doctors had not coped and had committed suicide.
Dr Brian Keithley (GPC) reminded the meeting that the GMC's primary role was to protect patients. “The GMC is right to favour the patient and this is the price of self regulation.” He asked what the public would think if a doctor had been accused of a sexual impropriety and was allowed to continue in practice and not identified and was then found guilty.
Dr Chris Tiarks (Highland) urged representatives not to let emotion cloud their judgment. “We came within a whisker of losing self regulation,” and to demand anonymity stretched credibility. One of the GPC's negotiators, Dr Simon Fradd, agreed. He said that generally complaints were not handled well, but it was usually the complainant not the GMC who publicised the names of doctors. “We cannot pursue a policy of giving protection to doctors, especially as we have a policy of opposing gagging of whistleblowers.”
The meeting called on the GPC to ensure that mechanisms were in place to offer support and advice to any GP accused of serious professional misconduct.
Attacks on doctors should carry harsher punishment
GPs want the criminal justice system changed so that an attack on a doctor carries the same punishment as an attack on a police officer.
This motion, which was carried, also supported the immediate removal of abusive or violent patients and called for health authorities and boards to ensure that doctors could see violent patients in a safe environment and to tell GPs when violent patients were allocated.
Dr Brian Goss reported that negotiations were taking place about increasing the punishment for attacks on doctors and on ensuring that there were safe places for GPs to see violent patients. He hoped that these would be concluded during the forthcoming session.
GPs should not have to give reasons for removing patients
In May the House of Commons select committee on public administration said that GPs should not remove patients without giving a reason to the health authority (15 May, p 1309). The conference took the opposite view and said that GPs should not always have to give a reason.
Removing a patient was done as the last resort when the relationship had broken down, Dr Darshan Suri (Enfield and Haringey), said in an empassioned speech. Patients did not have to give a reason for changing doctors. There were 35 000 GPs in Britain and 250 million consultations a year and yet fewer than one patient per doctor was removed.
But Dr Hilary Lavender (Lambeth, Southwark and Lewisham) disagreed. It was common decency to give an explanation. The patients often had personality problems and had been moved around. It was not necessary to make accusatory statements but they could be told what effect they had had on staff.
Dr David Pickersgill told the meeting that the right to remove patients was not under threat but the right not to give a reason was. He believed that in the majority of cases it should not be difficult to give a reason.
The conference …
Declared that GP principals must be able to retain their independent contractor status if they wished and called for a new contract for independent contractors
Resolved that home visiting as an obligation should be removed from the terms of service
Called for a campaign against requests to doctors for irrelevant certificates and reports
Believed that vocational training should remain at three years but that there should be an increase in the time spent in general practice
Deplored the way the secretary of state for health managed the provision of sildenafil (Viagra) in the NHS
Called on the government to recognise that only a consistent drive to increase GP numbers would avert the collapse of primary care
Supported the establishment of a working party to discuss the future structure of the LMC conference.