Saturday 14 December 2013

Meet your MP to save your GP - Toolkit

The NHS is stretched to breaking point. General Practice in the UK is high quality and uniquely cost-effective but is even more at risk.
Visit your MP's next surgery to tell them how General Practice can save the NHS!
Please add as comments to this post killer points for people to use in such meetings.

To start us off, here are some nuggets drawn from RCGP's The 2022 GP: Compendium of Evidence by +clare gerada, Nigel Mathers, Ben Riley and Mark Thomas.
  • "a health service based upon the GP is likely to be less costly than a hospital-based service and the aim should be to provide the maximum amount of care in the community" - p38 (ref 104)
  • the general practice consultation rate [per patient] has almost doubled in the last decade - p19 - from 3.9/year in 1995 to 5.5/yr in 2008 - p20 (ref 55)
  • 90% of all NHS contacts take place in general practice - p40 (ref 55)
  • "In England, an increase in just one GP per 10,000 population is associated with a 6% decrease in mortality" p 40 (ref 113)
  • "NHS Choices ... led to an increased [albeit appropriate] ... demand rather than preventing it from occurring in the first place" - p36 (ref 96)
  • Great table (4) on page 39 exploring key differences between generalists and specialists


96. Paul Nelson, Joanna Murray, Muhammad Saleem Kahn. NHS Choices Primary Care Consultation Final Report 2010
104. Department of Health and Social Security, Welsh Office. The organisation of group practice. 
A report of a sub-committee of the Standing Medical Advisory Board. London: Stationery 
Office, 1972.
113. Martin Gulliford. Availability of primary care doctors and public health in England: is there an association? Journal of Public Health Medicine 2002; 24(4): 252–4

Thursday 5 December 2013

Online mutual mentorship for GPs

Why do I need online mutual mentorship?
How would such a group discuss cases?
Where? Which social media platform should I use?
How-to operate a group - or at least how we plan to do it

Online mutual mentorship for GPs - the how-to

Draft working document. Please suggest revisions in comments

How we intend to operate our group


  1. Join Google Plus
  2. "Follow" one of the members of the Community
    This will make it easier for them to send you an invitation
  3. Accept your invitation to the Community
  4. Bring up the list of members of the Community
  5. Find the member with the impersonal name and the following icon:

    This is the Page which all group members should be able to use if they would like anonymity
  6. "Follow" this character.
    This will make it easier for one of the other group members to make you a "manager" of that Page
  7. Accept your invitation to become a "manager" of the anonymous Page
    This step is vital, as it will enable you to act as that Page to post anonymously.

       If you do not receive this notification, simply visit the anonymous Page, look for the "You've been invited to manage this page" bar and click on the "Accept" button:
  8. Unfollow the anonymous Page
    (as there does not need to be a public record of who is in our group)


  1. Confidentiality
  2. Respect
  3. No personal medical advice

Joining the discussion ("supervising")

If you find a see a post relating to a case, join the discussion! At least during the early part of the discussion, it may be best to stick to questions for the narrator to contemplate rather than suggesting solutions.
If you want to start a new discussion, feel free! Hopefully this group will be informal and friendly and not have to rely too much on rules.

Posting a case ("narrating")

If there is a scenario you would like the group to consider, please post using the anonymous shared Page (at least at first - feel free to identify yourself in free text should you wish). To start using Google Plus as this Page:
  1. Click on your icon in the very top right of your browser window
  2. Click on the name of the anonymous Page in the list that appears
  3. A new tab will open showing the profile of the anonymous Page
  4. In this new tab, navigate back to the Community
  5. Now you should be ready to post under the cloak of [relative] anonymity!
  6. Please do not use this page to post outside our Community
Instructions for posting
  1. Type a very brief title in the "Share what's new ..." box. Something like "depression dilemma"
  2. Click "Share"
  3. Once this brief message has been posted, select it and click in the "Add a comment..." box. Now you can provide a full description of the case and the issues it raises for you
  4. Be ready to respond to comments!
  5. Remember to use the anonymous Page when you reply to any comments if anonymity is important for you.
This mechanism is to make sure that anyone sitting next to you when you open Google Plus does not see the details of the scenario unless you click on it, which presumably (please!) you will only do when not overlooked.

Online mutual mentorship for GPs - the where

Draft working document. Please suggest revisions in comments

There are many social media platforms available. What features would the ideal platform have?


Private groups
Accessible from commonly-used devices and networks
Easy to use
 - this needs to be balanced against accessibility


Threading of conversations
 - so that each case can have it's own discussion thread
Vehicle for anonymous posts
Free of charge
 - to allow for scalability
 - for ease of admininstration

It is difficult to find a platform which fulfils all of these criteria. One could host a system on one's own servers, either using existing forum-type software (such as phpBB) or bespoke software. A completely bespoke solution would be extremely expensive, and even existing software would need customising in a way few GPs have the skills for.

Any costs would have to be borne by group members or sponsors. A sponsor is unlikely to be interested in advertising on the group unless there was a substantial membership. This immediately presents a considerable hurdle: how can one fund the development and promotion of a new platform until then?

Of course, there are several social media platforms already available, funded by advertising (or will be), free of charge to the user.


The 140 character limitation and lack of private groups really render Twitter unsuitable for this application.


Facebook is attractive as it is the most widely used. I would argue, however, that there is a limit to how much it can be trusted.

Its funding model has apparently not yet been finalised, and so it is uncertain how it will use users' data for monetary gain.

Users have been suspended as a result of posts on private groups, implying a lack of respect for privacy from Facebook staff of content within these groups.

I can find no way of permitting anonymous posts. Users can post "as" Pages but not within groups.

Google Plus

For me, Google Plus seems to tick all the boxes. Its funding model is well established (serving advertisements to users based upon words they use or search for).

Its downsides are that fewer GPs in the UK are yet familiar with it. Also, many seem to be concerned about privacy in relation to sharing their data with Google. However, as far as I am aware, this data is only parsed by computers, not staff, to determine advertisements likely to be of interest. I have not heard of any instances of monitoring by Google staff of content within private groups.

Online mutual mentorship for GPs - the how

Draft working document. Please suggest revisions in comments

Let us extrapolate a formula from Balint groups

Size - 10-20 members

6-12 members are recommended for Balint groups, but an asynchronous group probably needs to be larger to reduce lag times waiting for responseses.


The group will need 1-2 leaders ("owners") for administrative purposes. It could be argued that every group member should be an owner, giving everyone the ability to perform admininstrative functions, up to and including deleting the whole group.
Will discussions need chairing?

Confidentiality and privacy



- in clinical contact with patients
- invited by another member
- trusted
- reflective
- humble (so as not to assume their way of practising is best)


Launer advises "ask only questions"


The Balint Society (2003). Essential and desirable characteristics of a Balint Group. Compiled by Paul Sackin.
Launer J (2013). Workshop at Birmingham and Solihull GP trainers' conference 29 November 2013

Online mutual mentorship for GPs - the why

As a regular user of social media, I have been surprised by the degree of support I have derived from it. Public or large fora are a great place to learn and to interact with opinion leaders. Less expectedly, perhaps, one can form very real friendships.

However, there is a limit to how much one is willing to share in such fora. In particular, it is rare for someone willingly to expose a vulnerability in public, especially if it could damage their professional reputation. However, it is by reflecting on these very vulnerabilities that must be of highest importance for any professional in maintaining and improving their competence.

GPs face emotional and professional challenges every day. Most helping professions have well established systems for supporting each other. GPs now have a system of appraisal to support their professional development and applications for revalidation: these meetings occur only once a year and rarely provide much emotional support.

There have been many attempts at meeting this need in general practice. Local discussion groups of various kinds exist. Often, these comprise a factual educational component, sometimes with a guest speaker, in which case the group tends to be larger and more formal. One to one coaching or mentoring also takes place on a small scale.

Balint groups have been promoted as an explicit way of addressing the need of GPs for emotional support by encouraging in groups the exploration psychological aspects of consultations. Although there has recently been renewed interest in Balint groups, they never have achieved widespread adoption. John Launer suggests this may in part be due to the exclusive focus on psychological aspects. I suspect logistical obstacles such as spare time and local availability of like-minded trusted colleagues are also important.

Launer champions the concept of narrative-based clinical supervision (which he also calls "conversations inviting change"). Such conversations can take place informally in any setting, such as over the kettle when colleagues have just a few minutes to spare between patients. He opines: "the time has arrived for experimentation and pluralism in clinical supervision for GPs".

I would suggest that online social media could be a very useful setting for clinical supervision. Geographical separation may assist confidentiality and therefore openness. Even face to face and verbal communication is possible using video and telephone conferencing technology respectively. However, these benefits need to be set against the benefits of asynchronous text communication, which will allow participants to communicate whenever is individually convenient for them, in the now established manner of social media.

Launer J. Moving on from Balint: embracing clinical supervision. BJGP 2007; 57(536): 182–183.

Ten Commandments for General Practice

  1. Have humility. You don't know everything (and neither does anyone else, including the eminent Doctors in white coats from your local "Centre of Excellence"). 
  2. Listen rather than speak and use the power of silence. It's amazing what patients or colleagues will say when there is a silent pause and you will gain insight. 
  3. Respect yourself and then others may respect you. If you act like a doormat do not be surprised if others wipe their feet on you.
  4. In a busy professional life delegate appropriately and support those to whom you delegate. Remember you are the best trained and most adaptable member of the team but also the most expensive. Put your effort where it adds value - for you, your patients and your team.
  5. Try to learn something new each day.
  6. Remember you are running a business. You have to balance the books. People's incomes depend on you.
  7. You and your team are a limited resource. If you waste resources you deny patients. You cannot do everything for everybody.
  8. Prioritise patients with the greatest healthcare needs, lest resources be diverted from them.
  9. Remember your patients' and colleagues' problems are their problems and you can help them but you cannot take their problems onto yourself: you have enough of your own to deal with and it would unfair on you, your family and those who love you.
  10. You cannot change the world but you can change bits of it. Change is made by those who refuse to accept the status quo. Keep nudging and eventually change will result.
developed from +James Kennedy's original.

Sunday 10 November 2013

Solutions to A&E

General practice and A&E departments are at crisis point responding to growing demand and expectations. +Mark Robinson has the solution! Do you agree with him? I certainly do.

Tuesday 5 November 2013

Top tips for GPs

Inspired by online conversations between GPs, +James Kennedy posted this sage advice on Tiko's GP Group on Facebook
I have been intrigued on this site to see the variety of ways GPs practice our art. It is bringing out the philosophical side of me. I do wonder if we should as GPs have a few practical "commandments", principles that will help us to survive and enjoy our professional life and practice in a professional manner. All suggestions welcome but here is my starter for 10 in no particular order:
  1. Have humility. You don't know everything (and neither does anyone else, including the eminent Doctors in white coats from your local "Centre of Excellence"). 
  2. Listen rather than speak and use the power of silence. It's amazing what patients or colleagues will say when there is a silent pause and you will gain insight. 
  3. Respect yourself and then others may respect you. If you act like a doormat do not be surprised if others wipe their feet on you.
  4. In a busy professional life delegate appropriately and support those to whom you delegate. Remember you are the best trained and most adaptable member of the team but also the most expensive. Put your effort where it adds value - for you, your patients and your team.
  5. Try to learn something new each day.
  6. Remember you are running a business. You have to balance the books. People's incomes depend on you.
  7. You and your team are a limited resource. If you waste resources you deny patients. You cannot do everything for everybody.
  8. Remember your patients' and colleagues' problems are their problems and you can help them but you cannot take their problems onto yourself: you have enough of your own to deal with and it would unfair on you, your family and those who love you.
  9. You cannot change the world but you can change bits of it. Change is made by those who refuse to accept the status quo. Keep nudging and eventually change will result.
What would you add to this list? Please feel free to suggest additions/amendments in the comments below.

Creative Commons Licence
James Kennedy has kindly allowed this post to be used "in any environment you wish".
Thanks, Jim. I interpret this as equivalent to a Creative Commons Attribution 3.0 Unported License

Sunday 3 November 2013

Pills, bills and bellyaches: a peek behind the scenes at a GP surgery

Brilliant article in The Guardian by Stephen Moss describing the reality of general practice: what we do and the pressures we face.

Thursday 24 October 2013

Thames Valley Faculty Chairman's report 2013

It has been a joy and a privilege to represent college members in Thames Valley Faculty for the last nine years, the last three of which as chairman of the board. This final report to you comes tinged with an inevitable emotional overlay. Should I apologise for that? I found it more difficult than ever to find the words for this report, which therefore became longer than ever! I should definitely apologise for that. However, your Faculty just does so much.

I’m delighted to be able to say that two of the highlights of the Faculty year, namely our symposium and the management course, continue to flourish. Our symposium this year was held again in Thame and was well attended by both Associates in Training and established members. RCGP President Prof Mike Pringle delivered the inaugural annual Liz Bingham memorial speech. Liz gave so much to College and Faculty, it is fitting that she should be remembered in this way. My thanks go to Michael Mulholland and his team for planning this year’s event.

Management course
Greg Simons, Chris Morris and Nicky Turner have now made their mark on our management course (initially set up by Bryn Neal, of course). This seems to be as popular and highly valued by delegates as ever. It is great to see this continue as a fixture which members can rely upon. Thanks again, Greg, Chris and Nicky.

Education programme
Nicky Turner’s main role in Faculty is to run our programme of educational events. Under her brilliant direction, this had reached the exciting point of being able to look to address members’ educational needs rather than simply what is popular. Any GP will understand the distinction and the benefit thereof! We had a slight hiccough during this year for personnel reasons outside of local control but, happily, the programme is now firmly back on course. Our courses are becoming more popular as they become established, so book early to avoid disappointment. Check your PDPs against our programme now!First5
More recently, we have worked to support our trainees and new members in particular. Regular First5 meetings (for those in their first five years of membership) are now taking place across the region. I am particularly grateful to our First5 reps, Sunaina Wanninayake and Sunaina Khanna, for their work in this area, and would like to take this opportunity to wish Sunaina the very best as she relinquishes this role.
I am particularly pleased to be able to share with you that our Provost Ken Burch, who oversaw a mentorship programmes when he was Chairman, has been working with Shamila, Sunaina and a band of volunteer mentors to rekindle this popular and much-needed scheme. Whilst appraisal provides valuable guidance for us all, informal meetings with a wise colleague to guide career development can be invaluable. Details of how to join our mentorship scheme will be announced imminently.

We have been fortunate enough to have trainees who have found time in their ever tougher training schedule to devote to Faculty and College. Amongst our AiT reps this year, Amar Latif has represented Thames Valley trainees at the national AiT committee. We have been pleased to support social events for AiTs. This year I’m told they have not ruled out allowing established members to attend their upcoming Ball!

One of Ken Burch's many roles as Provost is to encourage members with the right experience to apply for Fellowship and support them through the process, as well as to chair the fellowship nomination committee.  As with anything Ken undertakes, he very often goes the the extra mile to make sure everything is in place. Thanks to his tireless efforts, we have recommended 12 members for fellowship this year.  It is a relatively straightforward process, so if this is something you are interested in, do contact Ken for advice.  Further information can be found on the main College Website.

A very new initiative for us has been establishing connections to support family doctors in Myanmar (Burma). Family medicine in Myanmar is in its infancy. It is fantastic to be able to support them as best we can. This initiative has been led on our side by Eleanor Vogel, Caroline Nixon and Sundee Soe-Naung. The energy with which they have embraced this project has been breathtaking. Already they have run a highly successful fundraising event on our behalf at St Hugh’s College, Oxford. I have no doubt that this work will be hugely beneficial for primary care in Myanmar and would like to wish them every success and pledge our support in this venture.

We are blessed to have such an enthusiastic and vibrant board. I always come away from board meetings with such a sense of energy. Colleagues express and debate with mutual respect their views to reach a consensus on everything from Faculty business to the Health and Social Care Act through the MRCGP exam to data protection. When such discussions lead to a rethink, they are all the more valuable.
The dedication and enthusiasm of colleagues has been remarkable and I thank you. Writing this report every year causes me to realise what a debt of gratitude we owe to so many talented and wise GPs for the work they do on our behalf on a voluntary basis. I know I have learnt a tremendous amount from you. With your commitment, I know that Faculty is not only in safe hands but will serve its members better and better.

If truth be known, the success of your Faculty is, in many ways, down to our tireless and highly skilled administrative and managerial staff. When I first joined the board, Sue Daniel valiantly fulfilled this role from her home office in Maidenhead. With the move to Andover, we were fortunate enough to recruit Jenny Gorski, who now provides business support for faculties across the region.
Shelley Coburn, our current administrator, just makes things happen for us. She has to deal not only with your needs but also with the requirements laid down by College and the tax man to keep everything above board - as they most surely are. She has been joined this year by Tania Hilton and Julia Hanlon in turn, who have helped to make sure that our education programme runs as efficiently as you, our members, deserve and require.

You hardly need me to tell you about the challenges of rising demand and expectations, limited resources and incessant system change. Primary care continues to lead innovation to respond to these pressures. The core challenge for your Faculty, I humbly suggest, is to listen to the concerns of jobbing GPs so that these may be represented effectively by College at the national level. I know GPs in Thames Valley, with their patients’ interests first and foremost, have a powerful voice. Your Faculty can coordinate this voice to have an impact on national policy.

Your representatives on Faculty board do present eloquently their views on your behalf. If you would like to join the board and contribute to this debate, please do get in touch.
We recently sought your views on assisted dying using an online survey. If you have any other thoughts about how Faculty might best discern and represent the views of our members, please let us know, either through your local board representative or directly to our office.

If you will indulge me for just a moment longer, this is the end of a significant chapter of my life. I have learnt a great deal from Thames Valley Faculty and I hope I have been of some service. Although I am moving on, it will be business as usual for your Faculty, composed as it is of such dedicated, thoughtful, capable and connected GPs. I pass the baton to a uniquely talented group of your representatives.

Good bye and thank you.

Thursday 3 October 2013

Question to Jeremy Hunt at RCGP conference 2013 (Harrogate)

Following the speech of Jeremy Hunt, Secretary of State for Health, to RCGP conference, I asked him how he planned to control demand. Some might say his government and the preceding Labour government have done nothing but fuel demand for NHS resources.

This was the question I posed:

Improving access, awareness and screening programmes may have been very well intentioned but requires patients to compete for resources, and benefits providers paid for activity (and their shareholders) disproportionately. 

Health education to empower self care, strengthening of support networks and meeting social needs have great potential to improve access to healthcare by reducing demand. 

What policies will the government introduce to control demand and ensure NHS resources are concentrated on those most likely to benefit?
He answered with reference to self care of chronic diseases (diabetes). I liked his use of the term "normally well"; I would have preferred to hear how he planned to spend less on them rather than more.

Wednesday 29 May 2013

What’s special about being a Grassroots GP?

In May 2013, Pulse magazine (for GPs) asked me to write a piece about myself as a self-styled grassroots GP for their "Working Life" section. I failed to follow the brief, so they did not accept it! Here it is, anyway.

What’s special about being a +Grassroots GP?

What a privilege it is to be my patients’ first professional port of call for just about any health concern.  Working, and sometimes living, in the same community, there can be a powerful sense of working together to restore health.  Intervening in a health crisis, whether it be supporting them through an episode of depression or admitting them with appendicitis, can be profoundly rewarding.  However, demedicalising their condition and providing reassurance instead of intervening, where appropriate, has the potential to benefit not only the patient in front of me but also, by conserving resources, my surgery’s other 5,000 patients.

This will resonate with every GP.  What could be more rewarding!  This is the essence of grassroots general practice.

I started using Twitter a couple of years ago.  My intention was simply to “lurk” and follow current affairs.  Before long, however, I found myself following and interacting with medical colleagues and others interested in health policy.  Indeed, it is difficult to know how I might otherwise have made contact with colleagues of every grade, whether fellow grassroots GPs or more eminent.

As such, a group of us got together.  Some of the values we share are set out on our website at Within the industry that healthcare now is, we aim to give voice to grassroots GPs.  Specialists, drug and other manufacturers, academics, political parties and charities are undoubtedly all vital.  Unfettered by the pragmatism of generalists in daily contact with patients, however, health anxiety will continue to escalate and the health economy to overheat at the expense of the sick.

Our royal college is enriched by the wisdom of many senior GPs.  We certainly need them.  However, we believe that the views of grassroots RCGP members also need to be well represented.  I was delighted to read of Chair-Elect Maureen Baker’s aspiration for RCGP Council to be more accessible.  I believe having more grassroots GPs on Council and making better use of digital social media such as Twitter will help.

To this end, six of our group of Grassroots GPs (Martin Brunet, myself, +Pete Deveson, +Margaret Mccartney, Stuart Sutton and Jonathan Tomlinson) stood for election to RCGP Council.  Voting has now closed but I do hope we will have more grassroots representation as a result of your votes. [Update: I'm delighted to say that Margaret was elected]

Day in the Life: Dr John Cosgrove, Grassroots GP

My day job will be much like that of grassroots GPs up and down the country, facing pressures which seem to grow day by day, dealing with the expectations generated by those who seem to know our job better than we do.  However, more than matching any frustrations is the richness and variety of interactions, not only with patients, but with trainees and colleagues both locally and at other sites.

I recently joined +Midlands Medical Partnership (MMP), composed of 33 partners across 10 sites across Birmingham, with over 60,000 patients.  By grouping in this way, we believe we can meet the threats GPs and their patients face and make the most of opportunities in this Brave New World, while preserving the best of GP-led primary care and grassroots values to the benefit of our patients.  If you think your practice would fit well into this evolving organisation, do get in touch!

Ever since I qualified and joined RCGP eight years ago, I have been an officer of +Thames Valley Faculty RCGP (where I lived and worked until last year), representing the views and interests of grassroots GPs across that region.  I like to think that our faculty and board are now at least as accessible as ever.  On a personal level, I have found this involvement richly rewarding (if not financially!).  I know local faculty offices would be delighted to hear from any member interested in getting involved, so do get in touch!

In my down time, I am wont to pick up my smartphone and tweet.  I rarely have a set agenda on Twitter.  Indeed, some days the mood will not take me.  However, sometimes the temptation to interact, 140 characters at a time, is irresistible.  Mostly, but not always, the topic is primary care.  Of course, there is a limit to what is appropriate to post in such a public forum.  For those seeking guidance in this area, the RCGP Social Media Highway Code written by Ben Riley and Clare Gerada, is well worth a read.  That having been said, like minded souls on Twitter can be a valuable connection.  “Follow” me at @DrJohnCosgrove!