Helen Stokes-Lampard: Delivering the GP Forward View

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Helen Stokes-Lampard, Chair of the Royal College of General Practitioners, discusses the work being done to deliver the GP Forward View.

This presentation was recorded at our conference on Mental health in primary care on 7 June 2017.

Transcript

Hi I’m Helen Stokes-Lampard.  I’m a general practitioner in Lichfield in Staffordshire, I’m a professor of general practice education in Birmingham Medical School, but I’ve been invited to speak to you today because I’m the Chair of the Royal College of General Practitioners.  Now, for the avoidance of doubt, Medical Royal Colleges are about quality, standards and accreditation.  The BMA is the doctor’s trades union who does pay and rations, we are not the BMA.  We are very, very different.  So, one of the commonest questions I get asked, so just to be clear, Royal Colleges quality and standards, BMA pay and rations, not that I’m on a soapbox about that one.  My conflicts of interest slide as a sort of principal really, I don’t think there’s anything too surprising in there. 

So, our college vision as the future read, but I want to share with you our values.  We’re the heart and voice of general practice. We promote the principals of holistic, generalist care in partnership with other healthcare professionals and in partnership with our patients.  We’re committed to the equitable access to and delivery of high quality, effective primary healthcare for all and committed to the academic and practical development of high quality general practice.  

I share that because I think, when it comes to mental health issues, more than anything else, talking holistically about care that is entirely wrapped around the patient is so very important.  I also talk about general practice, unlike other specialities as being a three-legged stool where we have to consider the social and psychological elements of our patients’ lives as well as their physical ailments.  

So, just to be clear, a stool that is unbalanced will fall over.  If you don’t consider all those elements properly, you can’t be a good GP and you can’t treat your patients holistically, and as Paul’s eluded to, we do a lot of work in general practice.  Expert medical generalness is how we like to describe ourselves, and again for the avoidance of doubt, GPs are consultants.  Okay, let’s be quite clear, we’re just consultants in general practice, we work in our communities rather than hospitals.

So, I’ve only got a few minutes to speak to you about the general practice forward view angle on mental health issues.  As we all know, there has been a chronic under resourcing of the whole healthcare sector, the social care sector but in primary care we’ve been particularly disadvantaged as the proportion of resource we’ve had over the last decade, as a proportion of the whole NHS has been declining.  At one stage we were about 10.5% of NHS resource went into general practice, it dropped to an all-time low last year of 8.4%. That has a big impact on morale, it has a big impact on retention and it has a huge impact on the ability of people to remain as GPs and as Paul’s eluded to, the stress on individual practitioners is immense.  

In terms of mental health and our patients, long term conditions, 30% of people who have a long-term condition, also have a mental health problem, significant diagnosable mental health problem.  46% of those with a mental health problem, additionally have a long-term condition.  So, huge numbers of our patients are complex patients with multiple conditions as well as their mental health problems which is why I’ve come back to my three-legged stool.

Today we’re focussing on mental health but as a general practitioner we have to focus on holistic care and the entire health needs of our populations and obviously as you said, Paul, the vast majority of mental health problems are dealt with in the community.  However, the core ten-minute consultation which is what the vast majority of practices work to, is woefully inadequate for handling and dealing with complexities of mental health problems, and Paul, I just love your find the words video, I think it’s absolutely spot on and I will do my best to endorse and support what I can with it. 

So, the GP forward view; you’ll remember this chap, this is Simon Stevens.  He was brought in to save the NHS and he came up with a big clever plan called the five years forward view.  This was launched two and a half years ago.  At the same time, we were launching our campaign called Put A Patient’s First and Back to General Practice, and this was a collaboration with NAPP or National Association of Patient Participation, and our campaign asked for a lot of very clear things; resource, people, time, energy, mental health therapists and eventually we got the general practice forward view in April 2016.

So, general practice forward view was an innovative document, this only applied to England and I apologise if there are people here from the devolved nations that have got a different set of challenges in terms of commissioning of their healthcare, but I can happily take questions later but this is an England thing because this was what I was asked to talk about. 

General practice forward view, we as a college reviewed it in January this year to see how things were going, it was an interesting thing.  We rag rated everything of our twelve key things that we could rag rate at that point; three were green, three were red and six were amber.  The government themselves undertook an interim assessment of the whole five year forward view in March this year.  We were building up to the big hurrah, how’s it all going and then Mrs May did this to us.  And as you’ve said Paul, everything stops for a general election.  It has been staggering to me how you cannot get a simple answer to a simple factual question from any government agency at this time. 

In preparation for this talk, I wanted to ask for a specific up to date number on the IAP programme and how we were doing and of course I haven’t been able to get it, so I apologise, my hands were tied in a bizarre mysterious way call Purdah.  However, in response to calling the election, I brought this so for our college, Our Manifesto for Healthcare and Primary Care, six steps for safer general practice.  I didn’t practice saying that aloud before we called it.  Six steps for safer general practice is quite a tongue twister but I’m well versed in it now, the last few weeks have brought it along and what we’ve asked for is whoever the new government is, come Friday morning, that they implement in full the plans.  Simon Stevens came up with the plan, a well-intentioned, good plan, and the spin offs for that, the general practice forward view, and the mental health forward view are well thought through and well intentioned.  They don’t give us as much as we’d like, of course they don’t.  We all want more.  

However, they’ll balanced and well thought through and they’re not a bad place to be going from.  The worst thing that would happen on Friday is for a new government to come in and tear up where we’ve started from.  There is a good plan let’s please see it through. 

So, general practice forward view, this is basically what it promised: increase in the resource for general practice back up to that 10.5% over the next couple of years, 5000 more whole time GPs, that’s not people, that’s 4000 whole time equivalent GPs but 2000 extra practice nurses and three other allied healthcare professions, which has subsequently been clarified as 3000 IAPS practitioners, and this was the review, this is basically what the review said and what it did and in bold, most clearly here, is that we were given specific targets for those mental health therapies.  That’s 800 by next March, 1500 the year later and 3000 by March 2020, and just for the avoidance of doubt, IAPS, we’ve been so used to this new trendy term, IAP’d, this is an initiative improving access to psychological therapies, sometimes it’s worth reminding ourselves of what the acronyms mean, but this initiative is not practitioners necessarily employed within general practice and again eluding to what Paul has touched on, general practice tend to work as teams so we employ nurses, we employ pharmacists, sometimes we employ physiotherapists in the community as part of our teams.

One of the slight risk in this health programme is because people aren’t employed as part of the team, there is a risk of them not being integrated into the team.  One of my jobs is to flag that, keep saying it, it’s fine we work really well with loads of people we don’t employ, district nurses are a good example, but when we’re not employed together, then actually contractually we’re not bound and if we’re not bound there is a risk of drift and there is a risk of other priorities coming in. So that is one of my flags for the day, don’t mind who pays the salary, don’t mind who they’re working for, we’re all in the NHS, we’re all in it together for patients but let’s make sure the communication isn’t just good, we need the communication to be excellent between us. 

Fifteen years ago, we had a CPN based in my practice.  It was great, she knocked on my door, I knocked on her door, we talked about our patients.  Got ripped away a decade ago, no idea who the therapists are who see my patients, but the good news is, in Staffordshire where I work, we’ve started to have more of them.  The patients aren’t complaining of 6, 8, 10, 12 month waits just to be assessed for their mental health problems.  A patient came into me last week and said, “Dr Helen, I’m having CBT next week”.  I said, “Are you, I only referred you last week”.  “Yes” she said, “there wasn’t any space in that nice group therapy session you said they’d probably send me to, but they’ve offered me one to one CBT instead”.  Good grief, CBT hasn’t been available in my part of the country for several years, suddenly things are filtering through.  There are green shoots happening and so there is the small mention of hope as well. 

What facts I could get out are that we, now there have been over 500 new therapists overall in the whole IAPS initiative, in London.  That’s 30/31 CCGs in London.  30 CCGs in London have benefited from more IAPS practitioners being recruited.  This is good, but no necessarily primary care, but it’s a step in the right direction and there’s lots of soft data that things are going the right direction. 

We’re pushing for pilots for integrated therapists, for more serious mental health conditions too.  I think it’s important that we get that communication joined up because not all our patients in primary care, half of the less severe side of mental problems.  We have a lot of patients that we manage nowadays, the vast majority are being managed that is happening in primary care too and that’s a serious edit and we really need the help of these colleagues. 

So, there’s lots going on.  Feel free to get in touch with us.  Thank you I’ll stop there. 

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