Let Them Eat Cake

Published in The Guardian

Despite petitions and public protestations, The Prime Minister, Boris Johnson is sticking by his guns. The Health Secretary, Matt Hancock is insisting that the Government are already doing enough, with an array of other white men in suits telling us why he’s right, whilst ignoring the voices of over 2000 leading Paediatricians (what do they know, anyway?!).  Whilst Marcus Rashford calls them to account and celebrates the great swell of public support, they want others to step up to the plate and take responsibility. But there seems to be a significant difference to what the government believe they are doing about the issue, what local councils are receiving in terms of help and what communities are experiencing. Learning to listen is one of the core facets of compassionate leadership.

 

“Of all the skills of leadership, listening is the most valuable — and one of the least understood. Most captains of industry listen only sometimes, and they remain ordinary leaders. But a few, the great ones, never stop listening. That’s how they get word before anyone else of unseen problems and opportunities.”

— Peter Nulty, Fortune Magazine

 

Here in Morecambe Bay, I’ve had the privilege of hearing Trina, a brilliant member of the community in Morecambe, give her testimony to Heidi Allen MP and Frank Field MP from the select committee for the Department of Work and Pensions, and more recently to the Chief Medical Officer, Prof Chris Whitty, when he visited the Bay. Trina is an amazing woman. She keeps a freezer full off food in her front room to feed members of her local community who are on the ropes or have been sanctioned. She knows what it is to live with the experience of poverty and the complex issues involved. I love the way in which she fearlessly speaks truth to power:

 

“Ending up on benefits isn’t always as simple as losing your job. It can be the result of bereavement, illness, injury, or a breakdown in a relationship. It’s a culture shock. For me, one day I had a grand a week coming in. The next day I was applying for IS. It took 14 weeks for my payments to come in. 14 weeks where I still had to pay the rent, pay bills, feed my child. You default on anything on a contract. Worry about it later. And you sell all your ‘nice things’ for pence, to keep a roof over your head. Then the fridge breaks – or the cooker, or the washer – but you’re still only getting your IS payment, not housing benefit or tax credits. It’s different now, it’s all UC – but that’s harder, coz it’s all rolled into one so you don’t even get that small amount of IS. With no other option (you can’t get normal credit) you go to Brighthouse (or the current equivalent) or you get a loan from Deebank/Provident/Greenwoods. You pay 4x as much back in total, but it’s only £5 per week. Your credit rating gets worse because you’ve defaulted on all your ‘luxuries’ – contract phone, sky tv, landline phone. Debts become bailiffs knocking on your door, and if you hide from them long enough… county court judgements. You’re still trying to learn to re-budget on less than 30% of what you used to have. All whilst dealing with illness, bereavement, disability, or social workers on your case because you were a DV victim and the police involved them. You move house because you can’t afford the rent. Then you’re sanctioned. Because despite telling the job centre three times that you’ve moved, they sent your appointment letter to the wrong house. Or you were in hospital. Or your child was sick. You appeal, but they uphold the sanction. You try to re-budget again. Your ex-partner decides they don’t want to bother with the kids anymore. So they stop paying child support and disappear. The CSA/CMS ‘can’t find them’ despite you providing their address and phone number. You try to re-budget it again. If that doesn’t make you think twice about judging people in poverty, consider going through that – which was my experience in 2009 – in the midst of a global pandemic, when there’s no jobs, food has gone up 60% you’re frightened to leave the house in case you get sick….And the world and his wife are taking to social media to espouse how you’re a shit parent and need your kids taken off you, because no matter how hard you try to explain that you’re not a scrounger, they tell you that you should use your non-existent money to just make soup.”

Trina’s experience is replicated thousands of times over. And whilst national leaders tell us they have already done enough and it’s not their responsibility to ensure that children are fed, let us examine these claims, with some help from the BBC.

 

The BBC ask – How much money is the government spending?

By BBC Reality Check

 

“Earlier, when pressed on free school meals, the prime minister told the BBC “there’s £63m specifically to help deal with holiday hunger and with pressure on families,” referring to payment made to local authorities in June.

However, the £63m was for a “local welfare assistance fund” to “assist those struggling to afford food and other essentials” and was not just to feed children.

Guidance for the funding stated that the government “anticipates that most of the funding will be spent within 12 weeks”, meaning that it was expected to have been spent before the end of September.

In England, about 1.3 million children claimed for free school meals in 2019 – about 15% of state-educated pupils.

Analysis by the Food Foundation estimates a further 900,000 children in England may have sought free school meals since the start of the pandemic.”

 

SO – just to be REALLY clear – the £63 million the government are talking about has ALREADY been given to councils (in August) and has ALREADY run out (as by the government’s own admission it was only expected to last for 12 weeks from the time it was given). It amounted to 34 pence per child, per day (the maths is fairly straight forward – £63million, divided by £2.2million – the number of children now needing Free School meals, see above facts from the BBC and then dividing this amount by 84 days – that is the 12 weeks for which the funding lasted). The government keep saying that they have funded councils to fund FSM vouchers, but a) this is no longer the case – the money has run out (as the Conservative Leader of Warwickshire County Council informed the government) AND b) it was woefully insufficient anyway to provide adequate nutrition! This all matters because the government are telling us that they are doing enough, but they plainly are not.

 

The things is that most of us find it hard to comprehend the difference between a million and a billion pounds, because we never encounter that kind of money. I find this graphic from reddit really helpful because it demonstrates it in a simple form. £63 million sounds like a lot of money, until you compare it to the £12 billion the government have spent on an ineffective test and trace system. They seem to be able to find massive funds for public health schemes which are failing, on the one hand, whilst unable to do provide sufficient funds for programmes that we know make a very real difference, you know – feeding hungry children.

 

With food bills possibly set to rise as the prospect of a no-deal Brexit becomes all the more real, the problem of hunger, not only for those already in poverty, but for many more families, currently just about holding it together will be felt ever more acutely. History teaches us that widespread hunger leads to civil unrest and sometimes even revolution. Now is not the time to remain entrenched in ideology. Now is the time for humble listening, and a change of heart. When the people are unable to buy bread, beware of the detached and senseless arrogance that cries, “Let them eat cake!”

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What Next for General Practice?

Last week, I had a sixth form student spend the week with me. She is hoping to go to medical school and is gaining the necessary work experience ahead of her applications. It was so great to be able to share with her the variance of my work and the great privilege it is to be a GP in the community. On the first day, we saw people with all kinds of problems, often interlinked or overlapping. She was amazed by how well I know my patients, not just the conditions they have, but them as people and the complexities of their lives. At Ash Trees Surgery, the practice where I am a partner, we run personal lists, in which we as GPs always see the same set of patients, supported by 2 other doctors, for times when one of us is not around. It gives us the opportunity of building fantastic therapeutic relationships with the people we serve and we get to know them really well. Our patients love it, we love it, and it has been a ‘traditional model’ of General Practice in our local community.

 

However, things are changing (not immediately in our case, but faster than perhaps we would like), and we (as GPs) and people generally, are going to have to get used to it, not just in Carnforth, but across the whole of the UK. I’m not writing this blog post as an idealist, but as a pragmatist. There are many things I wish were not changing, but we are reaching a point at which the scales are tipping and things simply cannot remain as they have been. Many GPs know this already and are making bold and difficult decisions to try and work differently, but many of us keep harking back to yesteryear and wishing we could turn the clocks back.

 

The issues facing us are stark:

 

1) We simply will not have enough GPs within the next 5 years to carry on working in the ways we have done. 40% of current GPs will be retiring within the next 5 years or moving into other work. (http://www.telegraph.co.uk/science/2017/07/30/nearly-40-per-cent-gps-plan-leave-nhs-within-five-years/).

 

2) The promise of 5000 more GPs will simply not come to fruition and certainly not in the time frame needed. Actually, a plan is afoot to replace some of the GPs with ‘Physician Associates’, people who have a science or allied degree, who have then done a conversation course and can do some (but certainly not all) of the work of a GP. They will also neeed supervision by GPs. Health Education England are having to cut GP training in order to make way for this new breed of health care workers (yet unproven). The Royal College welcomes the development as a support, but not a replacement of GPs. (http://www.pulsetoday.co.uk/your-practice/practice-topics/education/gp-training-cuts-necessary-to-allow-hee-to-develop-physician-associates/20034643.article#.WUrZgli-YHU.twitter)

 

3) The new generation of GPs, do not want to become partners and therefore the old partnership model will soon become entirely unsustainable. The results of a recent survey, carried out by Pulse of GP Trainers about the future careers aspirations of their trainees is pretty stark:

Only 6% said their trainees wanted to go into partnerships;
49% said their trainees wanted to become locums;
28% said their trainees wanted to go abroad
30% said their trainees wanted to find a salaried post;
4% said their trainees wanted to change career.

 

So, in summary, the older GPs are retiring, we’re not recruiting enough new GPs and those we are recruiting, simply don’t want to work in the ways we have been used to.

 

The Five Year Forward View has been trying to encourage us all to reimagine General Practice and how we might hold true to the values of this bedrock of the NHS, whilst adapting towards the future that is coming. I think we have some options, and GPs need to think clearly and carefully about which direction they want to head in. But even more importantly, the people of the UK need to recognise that change is afoot and GPs are simply unable to work as we have done previously. The demand is too great and the resource simply is not there to carry on as we were.

 

The first option, is for GPs to bury their heads in the sand and hope that all this might not be true, to become more entrenched in their position and wait for things to be done to them. I believe this will be harmful for General Practice itself, as it will mean a decrease in resources, an increasingly burdensome workload and significant burnout. But I also believe it is detrimental to the NHS as a whole. We neeed to break down the barriers that have divided us and work more holistically across what is a very complex system. Waving the flag of traditional General Practice is admirable in some ways, but I think it might prevent us from stepping into the future that the nation now needs from its NHS.

 

The second option is for GPs to federate with other practices, keeping hold of some of what they love, (a perceived sense of autonomy, the ability to run their own business, to stay part of a smaller team) whilst benefiting from sharing some functions like training, recruitment and maybe some staff with other practices. We have done this in Morecambe Bay (thanks to the Stirling work of Rahul Keith, John Miles, Lauren Butler, Richard Russell, Graham Atkinson, Chris Coldwell et al).  However, the federated model has to be given true commitment and financial support or it will accomplish very little. Practices cannot go back to competitive mindsets or taking care of their own needs first. It requires a bigger heart and a more open mind with genuine behavioural change.

 

The third option is to form super-practices. We have two in our area now (Bay Medical Group in Morecambe – > 60000 patients  and Lancaster Medical Practice >50000 – also both part of our federation). There are some huge advantages in working “at scale”, but it is not easy and certainly not a smooth transition. GPs have to learn to trust each other and be willing to have difficult conversations around buildings, drawings, policies etc, let alone learning to work differently. But more than that it is very hard to learn how to deliver really good General Practice in a personal way, whilst trying to reconfigure the team and establishing a really good culture. However, this model definitely allows new ways of working to be more easily acheivable, if given appropriate OD support. Some recent work done in Gosport and showcased by the King’s Fund showed that perhaps only 9% of people who phone asking to see a GP actually need to see a GP. The reality is that people have become used to seeing their GP, but often they could be seen and treated more effectively by a pharmacist, a nurse, a nurse practitioner, a physiotherapist, a mental health worker, a physician associate or a health coach. Perhaps GPs need to let go, whilst patients learn to trust the expertise of others? How do we transition to this kind of approach without losing that amazing knowledge of a community and complex social dynamics, often held by a GP? How does a Multi-Disciplinary team function effectively for the best care possible for patients in such a dynamic? We are in danger of losing something very precious, but can we somehow hold onto it in a different way?

 

The fourth option is to allow a “take-over” and become a more active player in an Accountable Care Organisation. The take-over approach is not straightforward, but I’m not sure it is as terrible as it appears to many GP colleagues. What if an acute trust set up a separate company, lead by a GP as medical director, who understood and held the true values of General Practice in his/her heart (as they have done in Yeovil – https://www.england.nhs.uk/blog/paul-mears-berge-balian/)? The company, run by General Practitioners, holding true to the core delivery of General Practice, without all the difficulties of running a business, HR issues, estates, etc etc but with all the benefits of shared IT systems, easier access to scans, no duplication of work and direct access to services without all the current clunkiness, not to mention protected admin time! What if the salary was right and the dross was removed? What is it exactly that would not be appealing about this? It is interesting to me. Only a couple of years ago I would have been utterly opposed to this idea, but having given it thought and time over several months, exploring the possibilities involved, I’m in the place of thinking that the benefits probably outweigh the negatives both for GPs and our patients.

 

What we need right now is for us all to accept that the NHS, as we have known it is no longer functioning in a way that meets the need of the population we seek to serve. We know we need a greater emphasis on prevention and population health (I have blogged on this many times before and will do so again!). We also know that the system itself is vastly complex and is in need of major reform and reconfiguration. We need this not only for the people who use the NHS, but for those of us who work in it and are in danger of serious burn out. I hope with all my heart that General Practice does not drag its feet and prevent the revolution that is needed. Our case for more resource and more recognition of the fabulous work we do will only gain favour, if we also show that we are willing to be a part of the whole and a part of the change that must ensue.

 

 

 

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