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.