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Monday 24 October 2016
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London calling

Michelle Drage, chief executive of Londonwide Local Medical Committees, discusses how she and the organisation supports its members but also recognises the problems practices across the UK are facing

It claims to be the voice of London’s general practices, to challenge policy makers and provide advice to its members. The Londonwide Local Medical Committees (LMCs) has made all the right noises that may echo its members’ thoughts.
At the helm is Michelle Drage, chief executive since 2002, and she doesn’t shy away from promoting the Londonwide LMCs’ mission. When Management in Practice met with Drage at Londonwide LMC’s office in Tavistock Square she was on form when voicing her opinion of the government and showcased her frustration at the morale and financial crisis facing general practice.
Drage and the Londonwide LMC’s aims are admirable, but in reality what have they done so far and will they be able to fulfil what they set out to do?

Q So it has been announced that there will be an alternative to the existing GP contract by April 2017 that will support practices working 8am to 8pm, seven days a week. What are your thoughts on this?
A Well, we know nothing about what it will look like and I am not sure we actually want it, but my understanding is that it will be a contract with networks or federations, as opposed to individual practices.
Personally, I do not see why we should deviate from an adequately funded national contract to provide the services that people need with local flexibility. This is not our brilliant idea, this is the government’s idea, and so we [Londonwide LMCs] have come at it from a point of view of scepticism.

Q GP burnout is a topic that yourself and the Londonwide LMCs often discuss. You do a lot of work to help GPs, but what are you doing for the rest of the team, such as practice managers and receptionists?
A When I have spoken to practice managers I have made a point of saying it is exactly the same [as it is for GPs]. So the first thing we have been doing is creating networks [support groups] for practice managers. Our philosophy is, you cannot run a practice without supporting your staff, and they need as much access to support as a GP does.
So the message that is going out is exactly the same, whether it goes to GP groups, practice manager groups or nursing groups. And we are looking to use the same mechanisms such as mentoring and support. We are planning to roll that out to managers as well.

QWhat happened in these support groups?
A As you probably know, burnout and depression are very closely aligned, so they are therapeutic groups. They are not just sitting round moaning. They have a purpose; they have objectives and there are therapists there.
Obviously the best thing we can do is support them with prevention. So a lot of what we are doing we are reframing in that context.
For a long time we have had partners in the system that might be looking at access and effective ways of improving access.
Workload is the trigger for the problem that we have with burnout; unrealistic workload and high demand. And so refocusing what we are able to offer, either ourselves or with partners, on the particular workload issues that we have got, and enabling and helping – targeting the practice managers is a way of helping prevent problems.
It’s also about helping practices use their biggest resource, which is their patients, and remembering that their patient-participation groups (PPGs) are there because they want to see their practice thrive.
So helping them understand the problems and getting patients behind you is really important, as well as all the self-help stuff that PPGs tend to look at. It’s about using that force for good.

QYou were involved in the London Initiative Zone Educational Initiatives and Workforce (1993-94 to 1998-99), and it was supposed to help general practices in London with recruitment and retention.
A Well, the thing is it did.

QAt that time, yes. But yet we are still discussing these issues today.
A So at that time they were really successful initiatives and then the funding was pulled. And when funding gets pulled, it takes a while for these things to work their way through. But I would say we have not seen any real funding for general practice in London since then. In a way it is amazing, worrying and chilling, that it has taken so long to get this bad. And that has happened because practices overstretch themselves and they care so much they are prepared to provide stuff at costs to themselves and their own wellbeing.
So in a way it is absolutely clear, if you pull funding from initiatives that are designed to support recruitment retention and better workload management, sooner or later, despite everyone’s best efforts, it is all going to break down and that is what we are seeing now.

Q And how do you think practices can solve the issue?
A So the first thing, I think, we have to do is say it is not the practice’s fault. This complex set of issues has arisen despite practices trying really hard, and yes, there is always room for improvement of systems within the practice. But primarily, this is due to external factors. Practices should stop beating themselves up because they do not feel they are providing everything that they would like to provide. But it also means we need to engage with the political side and practices need to open their eyes to what the junior doctors are achieving, to what patient support can really look like and to put pressure on [the government] for the resources they really need.
What happens is resources do come, but they come for all the things that we do not believe in.

QLike what?
A Well, we do not believe, for example, that it is achievable for a seven-day service, and to manage the demand on expectations, without support from social services, and mental health and community services, and those will have been cut.  So before you go for a seven-day service, you need to make sure all of those basics are in place with the limited resources you have got, otherwise you will just share five days’ worth of staff and have to spread them over seven. You can be clever and creative with that, but at the end of the day, particularly in a city like London, where people move around the whole time, if you make an offer as a government or as a city that does not match what you and your patients think you need, that just ticks political boxes, inevitably you are going to get people’s morale down and demotivate them, and that is what we are dealing with now.

Q Londonwide LMCs aims to support general practices and develop their resilience in managing the workload finance.
A Well, we have got a movement. So we continue to refine the range of resources that we have got. We have set up our own particular GP resilience website, You can get that off our main website, and that has all sorts of resources, like posters, workplace management tools, guidance and so on. So that is one channel.
We have got lots of channels. There is a Facebook group called GP Resilience and you can participate in that. So really just widening the range of media that we use to get the message across. Because we recognise practices just do not have the time to even read the emails that float around between this, so everyone is overloaded. The challenge is to actually get resources into practices in the easiest way possible for practices to use.

Q In your 2015/16 Annual Report, you said that you want to further develop the Londonwide LMCs’ influence on policy makers by enhancing their insight into the challenges of London’s GPs. But what influence have you had on policy makers so far.
A So we think, in London, we have helped change the language.

Q What do you mean by this?
A In 2013 we produced our policy document, Securing the Future of General Practice in London, and it identified things that had not been identified before, like workload, workforce, overregulation and resources, and they were not dealt with in a way that people recognised.
So since then the language has changed, they [policy makers] are talking about these things; they recognise when we say people are burntout they need help. What they struggle with is how to do it. And we are now two and a half years on from producing that. We are just about to launch a sequel to that, which contains, from our point of view, ‘If you are going to do it, this is how to do it right’, and with a particular focus on the workforce.
So I think some of what is being delivered by the system has happened, some of the good things, because of the way we influence. The recognition that there is a problem, the recognition that you need to ensure that the wider determinants of health are addressed; that it is not just all disease-focused stuff. But you cannot expect practices to just pick up work that comes out of hospitals and be mini clinics, it takes time to shift that culture. So some of it has shifted.
The other thing they recognise is they cannot achieve what they want to do without the engagement of GPs at grassroots level. So I think, through our influence, they have recognised the importance of LMCs and the importance of working with us, even if the messages we are giving do not necessarily fit what they would like.

Q The support package that NHS England announced is not out yet, but what are your thoughts on it?
A See that pig flying across the room? It is about as likely to happen as that pig going across the room.
I wish they would just stop coming up with schemes and increase the pounds per patient and commission decent multidisciplinary teams. It would do so much more good for patients and practices to be able to manage their workload by having the right people in the right place.

Q Many practices outside of London look to how the capital is managing. For example, the population is always changing in London and now it is doing so elsewhere.
A Yes. Well, it is interesting isn’t it? We have validation exercises going on since as long as I can remember being a GP, but they have got harder, and harder and harder. And outside, in other areas, they have never had it before because patients did not move. Now we are picking up that, in places like Cambridge, patients are moving, and all of a sudden NHS England is doing list cleansing. And when you are a practice and you get 1,000 people targeted for being removed, that is a massive hit. And what we know is they are often wrong; the people do exist, they are still there, they still come to the doctors we have.

Q Where do you see the future of general practice?
A So my optimism is around the fact that if we can engage patients, and we are beginning to really do that, then we can get patients to buy into the fact that they really need to continue to have their GPs in their neighbourhoods, and that those GPs and their practice, and those they employ, should be supported. Then I think you begin to change the mindset. So there is a positive strand to all of this. But I think it is difficult for practices to see patients and patient groups in those terms, but actually they are our biggest allies; [patients] are our biggest headache, but they are our biggest allies as well because they vote, it is as simple as that.

Dr Michelle Drage MB BS FRCGP

  • Chief executive of Londonwide LMCs 2002 – present.
  • Elected regional representative on the British Medical Association’s (BMA’s) general practitioners committee (GPC) 1998 – present.