Saturday 29 November 2014

Outcomes AND activity based commissioning

Outcomes based commissioning is the way your healthcare will be funded tomorrow. It makes a lot of sense. Get all the medical staff together and pay them only is what they do makes a difference. That way, they can work out between them whose input is most valuable and when.

In truth, most health outcomes depend very little on medical science. Whether you take amoxicillin for your cough or simvastatin for your raised cholesterol isn’t going to make much difference compared to your 20 a day smoking habit and your household income.

So if we’re going to integrate, let’s amalgamate all budgets with the potential to benefit health. You’ll have a hard time finding a budget that does not. Let’s get all that money together and find the best way to help people live healthily for longer.

However, within that system, let us pay people for the work that they do. In particular, pay GPs for each consultation they undertake,

That way, if I as a GP spend time advising someone on their housing needs, I will be paid for my time. However, it is likely that it would be more cost effective for them to speak to their housing officer, and so the integrated system should do all it can to ensure that people in need of housing advice reach their housing officer first.

Similarly, someone understandably distressed after the breakdown of their long term relationship, might be encouraged to contact the psychological treatment service, Relate or perhaps a faith leader.

Even those with an problem likely to resolve without medical intervention, such as a viral illness, might be encouraged to take advice from a trusted family member or friend - or even the internet - and accept the small risk that the first diagnosis they receive might not with hindsight be 100% accurate. Within the context of either honesty or finite resources, this is in any case the only possible conclusion.

GPs might be nervous that their role be usurped by others. They need not. There is no shortage of dire medical need.

GPs might respond by requiring more consultation time for each condition. With modern IT, the solution to this is simple: cap funding to that appropriate for the anticipated consultation time for each new diagnosis.

In summary, outcome-based commissioning has the potential to drive integration only if components within each system are paid for their activity. Why base a person's livelihood on outcomes beyond their control?

General Practice: Selfridges or Tescos?

Where do you do your shopping? If you want a designer suit, I’d wager you’re more likely to go to seek a personal fitting from a high end department store on Oxford Street than to get it from a supermarket. However, if it’s a pair of socks or even a shirt you’re after, I’m guessing you’d make a best guess or take advice from your partner on the fitting, maybe even get a recommendation from a friend or internet review and pick it off the shelf when you next visit the supermarket. Otherwise, you run the risk of paying far too much for something bespoke that your washing machine will destroy.

When it comes to your health, if you fear you have cancer, you’re going to want swift, personalised, confidential and professional service and medical expertise. If, however, you have a snotty nose and a rotten cough, you’d probably be better off taking advice from your partner or even a trusted friend or internet site.

Since its inception, the NHS has provided, free of charge (at least at the point of use), the equivalent of a Selfridges personal shopper: personalised, confidential and professional access to medical expertise in the person of your GP for whatever medical needs - or none - that you might have. Just the job (in theory) if you’re worried you might have cancer or some other condition that, without medical treatment, might hasten your death.

Initially, good GPs were able to discourage people from consulting them about snotty noses and other conditions for which there was no effective medical prescription, simply by issuing simple reassurance rather than a prescription. However, even this has discouraged patients or those around them from giving simple reassurance (“you can’t be too careful”, “you can’t put a price [especially if someone else is paying] on health”).

Faced with problems which, quite frankly, were scarcely mentioned in medical school, many GPs succumb to the temptation to reach for the prescription pad: antibiotics (effective only against bacteria) for the viral illness, addictive sleeping tablets for insomniacs, scans and the false promise of surgical cure for back pain and now even cholesterol-lowering drugs for a longer life for anyone! The more enlightened GPs recognised that their patients’ real problems had no medical solution and set about as their patients’ medical advocates arguing on an individual basis for better housing, transport and even employment.

What is not to like! For no cost to users and no additional cost to tax payers, GPs now promise to address all life’s ills. Sadly, this is deceitful at best and, in reality, positively harmful, as it absolves sections of society with the ability to really make a difference - wise friends and family members, landlords, councils, employers and, most of all, government - of their responsibilities.

All this while our patients are living longer and therefore more likely to develop cancer and other conditions which sorely need medical intervention.

General Practice has therefore now reached the point where, with the resources of a single store on Oxford Street it is expected to deliver all the services of a national supermarket.

While general practice has largely simply absorbed this extra work, it has now reached the point where other sections of the NHS, such as A&E departments, have started to pick up this extra work. (In reality, thanks to general practice, very many A&E departments have seen no increase in demand, but have chosen not to contradict national statistics suggesting the opposite.) Quite reasonably, they refuse to take on such an open-ended commitment without additional resources.

The solution

The solution is simple: pay GPs for the work they do.

If as a result a Selfridges’ price tag for a Tescos' service seems too expensive, perhaps tax payers, government, council and local community will strain every sinew to see that a more suitable alternative is provided.

Can GPs please get back to fitting suits and let others go back to supplying socks, shirts and bread?

Please see my next post for a consideration of how this proposal might be incorporated into the current vogue, outcomes based commissioning.

This post was published on Huffington Post on 10 December 2014.

Sunday 23 November 2014

Notes from RCGP Council meeting 22 November 2014

This was my first RCGP Council meeting. Readers will be relieved to hear that I have been placed next to +Margaret Mccartney, who will therefore keep me honest!

Patient-Centred Care

In response to this independent inquiry published just that morning, I expressed my concern that it seemed to address needs relating to patients with long term conditions but risked overlooking the demands placed upon the health service by those without such needs. I cited Paul Little's observation from the James Mackenzie lecture the previous day that whilst it is laudable that 90% of respiratory illnesses are self-managed, the risks of reducing that proportion are enormous.

Outcome-based commissioning

I responded thus:
This proposal may make a lot of sense in the context of the management of chronic diseases such as hypertension and encouraging an integrated system. Equity of funding models between primary and secondary care is indeed attractive.
However, I have three main concerns:
1) My first relates generally to integration and the risk that GPs might become gatekeepers for access to all social care interventions. Given that GPs are already operating above capacity, we cannot afford to agree to take on new work, especially such a potentially large commitment and for which our primary training has scarcely prepared us. I would also worry about GPs' ability to determine social needs equitably.
It is therefore important that the development of such integration is led by GPs but consists of the incorporation of social and other workers into the primary healthcare team, rather than GPs taking on this work personally.
2) The most important variables in determining health outcomes - and hypertension resulting in stroke is a good example - are social: wealth, employment, education, social and family networks, cost and availability of food, tobacco, alcohol and drugs, planning, transport policy and architecture, to name but a few. The health system has no responsibility over these other than advisory, nor should it. Therefore, its ability to influence outcomes is greatly limited.
As such, it seems grossly unfair to base the livelihood of GPs and other healthcare professionals on measures over which they have limited influence. *this point was addressed by a previous speaker
3) Free access to GP means that we are consulted routinely about matters which are neither particularly medical, nor is addressing them likely to influence health outcomes in a tangible way. My ideal system would incentivise the healthcare system and society to share more of this work. An example of a service which has developed in spite of the current system is a chaplaincy service provided to patients of a practice in Birmingham.
I cannot see anything in outcomes-based commissioning which would achieve this. I wonder if actually activity-based fees to GPs for such work would be most appropriate. This will incentivise the development of other services which will be more cost-effective, less medicalising and will free up GP time.

RCGP draft position statement on obesity and malnutrition

Other speakers spoke powerfully against the medicalisation of the management of obesity.
Regarding the management of malnutrition, I made the point that whilst I was happy to offer dietary advice to my patients, I did not see why I as a GP should be involved in the prescription of food and other nutritional products, a task that dietician colleagues are well placed to fulfil.


I was pleased to learn that Council members are expected to adhere to the seven Nolan Principles of public life: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. I will explore ways of supporting the observance of these principles, especially accountability and openness. Watch this space!

In the meantime, I have updated my declaration of interests on and would encourage all doctors to do likewise.

The Impact Report 2014 was presented at the AGM. More detail is available in the Annual Report and Accounts 2014. As RCGP is a charity, these will be published on the website of the Charity Commision. I would welcome any comments on these accounts.

Sunday 28 September 2014

Setup guides for GP Confidential

How to set up a Google and Google Plus account

How to set up a "GP Confidential" community

(with apologies for the sound quality)

Join an existing community

If an existing community is looking for more members, they may well be glad to have you on board. Here is a group we have set up especially for the 2014 RCGP Conference "Resilience in Practice". As soon as members join, we will transfer administration of the group to you and leave you in private.

Wednesday 3 September 2014

Pulse Power 50 2014

My thanks to +Pulse Today for including my name in their "Power 50" list of influential GPs in the UK. I look forward to using any influence I might have to good effect!

This was their list:

  1. Maureen Baker
  2. Chaand Nagpaul
  3. +clare gerada 
  4. Richard Vautrey
  5. David Geddes
  6. Steve Field
  7. +Krishna Vardhan Kasaraneni 
  8. Mike Bewick
  9. Beth McCarron-Nash
  10. Michelle Drage
  11. Kailash Chand
  12. Nigel Watson
  13. +Kartik Modha 
  14. Naomi Beer
  15. Charles Alessi
  16. +Margaret Mccartney 
  17. Aneez Esmail 
  18. Una Coales
  19. Brian Balmer
  20. David Haslam
  21. Bob Morley
  22. Michael Dixon
  23. Amanda Doyle
  24. Harry Yoxall
  25. Ivan Bennett
  26. Charlotte Jones
  27. Andrew Green
  28. Louise Irvine
  29. +John Cosgrove 
  30. Alan McDevitt
  31. Colin Hunter
  32. Agnelo Fernandes
  33. Gordon Gancz
  34. Simon Plint
  35. Mike Pringle
  36. Amanda Howe
  37. David Wrigley
  38. Peter Holden
  39. +Paul Charlson 
  40. Tom Black
  41. +Peter Swinyard 
  42. +Phil Peverley 
  43. Helen Stokes-Lampard
  44. Joanne Reeve
  45. +Iona Heath 
  46. Joanne Bailey
  47. Dean Marshall
  48. Mark Porter
  49. Laura Edwards
  50. +Farah Jameel 
And Rising Stars:
  1. Tracey Vell
  2. Katie Bramall-Steiner
  3. +Julian Treadwell 
  4. Chandra Kanneganti 
  5. Chris Ferdinand
  6. Hamed Khan
  7. +Samir Dawlatly 
  8. Kamal Sidhu
  9. +Phil Williams 
  10. Seher Ahmed

Sunday 20 July 2014

It's make your mind up time: what do you want GPs to do?

Workload in general practice has become unmanageable. GPs work long into the evening and at weekends making referrals, writing reports, checking letters and test results, issuing prescriptions and managing their practice. General practice has been working beyond capacity for years. This was tolerable to a degree when pay was reasonable. However, the demand from society for GPs to do ever more work for ever less pay (and even less understanding) has brought the profession almost to its knees. Furthermore, there has been no investment in premises for a decade, so that many GPs are now working in wholly inadequate accommodation.

It should come as no surprise, therefore, that the existing shortage of GPs is due to become extreme. Many already close to retirement age are deciding to retire early. Others are emigrating, for example to the Middle East and Australia. Saddest of all, practices are closing altogether as they become unviable.

Clearly, significant investment in general practice is urgently needed simply to keep the service going. However, if the service is to be fit for the medical needs of the 21st century - such as improved access and longer consultations - society must choose what it wants GPs to provide.

Most of a GP's work can be divided into four groups.

1. Management of those who need, or who believe themselves to need, medical treatment

This is central to general practice. GPs are contracted for "management of [those] who are, or believe themselves to be, ill ... [where] 'management' includes ... such treatment ... as is necessary and appropriate" (Standard General Medical Services Contract para 8.1.2-3).

What we must treat and how has changed immeasurably since the inception of the NHS. The range of conditions we can treat and the complexity of the treatments delivered within primary care now is extraordinary. Tragically, resources have not kept pace.

On the other hand, our healthier population is, happily, less likely to succumb to bacterial infections and their complications. The tools of evidence-based medicine (including the ability to compare the value of different treatments using cost per QALYs (quality-adjusted life years) have helped to expose many treatments as either unnecessary or inappropriate.

Paid to care for a population of patients, it has been in the interests of responsible GPs to reassure their patients about which symptoms and conditions do not require medical treatment. Unfortunately, GPs have now been completely robbed of this ability. The ability of stories of health misfortune and non evidence-based miracle treatments to sell newspapers by the million has been irresistible to journalists. They care nothing for the ill health in the form of anxiety that they provoke, and there is no shortage of special interest groups to ensure that such stories reach the press.

Consequently, appropriate reassurance and the traditional low cost (low financial cost to NHS and low risk of harm to the patient from medical tests and treatments) wait and see stock-in-trade of general practice is becoming increasingly less acceptable.

2. Treatments of limited value

The cost per QALY mentioned above provides a helpful tool here. Particularly if GP time is factored in, the cost per QALY for providing treatments for self-limiting conditions (such as the vast majority of acute respiratory infections [Cosgrove, 2014], gastroenteritis, viral skin infections and even muscular injuries) would be exorbitant. Not only that, but the urgency to see a doctor before the condition resolves puts the system under immense pressure. Where drug treatments have a role, they should be equally readily available to all patients. Perverse incentives to consult GPs such as free prescriptions for medication available over the counter should be very carefully examined.

Cosmetic treatments - from minor surgery, to treating fungal nail infections and arguably even acne vulgaris - are also associated with high cost per QALYs. Most CCGs prohibit hospitals from even seeing patients seeking cosmetic treatment but GPs do not have that luxury. Indeed, although we are discouraged from treating such conditions, it can be next to impossible not to whilst maintaining an effective doctor-patient relationship.

As it is so very difficult for GPs to just say no, and increasingly so in this age of inflationary demand, society must choose between allowing the NHS to pick up this enormous bill and finding new ways to fund it. Given that GPs no longer have any influence on demand, they should be paid according to a tariff for the work they undertake like just about any other service provider. To what degree patients pick up this tab and how is a matter for government.

3. Non-medical interventions

No-one understands better than GPs that social factors (affluence, living and working conditions, exercise, diet, relationships, religious group, hobbies, weather) influence health infinitely more than medical interventions (Marmot, 2009). Indeed, as +Bastiaan Kole explained in his piece "GP or social worker? (2014)", such an understanding is vital and comes to GPs as second nature. However, influencing social factors is, in all honesty, beyond the gift of GPs. Not only that, but a GP has neither the training nor the perspective to judge the needs of their patient relative to those of another in social need.

Patients have become accustomed to consulting their GP when distressed in relation to difficulties at home or at work. Of course, for a minority, prompt medical treatment for mental illness will be the very best option. For many others, however, one has to ask whether assigning them a medical diagnostic label and offering them a shoulder to cry on in 10 minute instalments is really the best way to meet their needs.

As a society, we have immense questions to answer to understand why our most vulnerable see no alternative but to turn to doctors in such circumstances.

4. Managing risk factors

Another massive change has been the drive to identify, manage and treat medically not disease itself but risk factors for disease, such as raised blood pressure, cholesterol and cardiovascular risk, low bone density, obesity, pre-diabetes and smoking to name but a few. No-one can deny the benefits of reducing such risks. However, the lifestyle advice given to those with these risk factors is no different to the advice applicable to anyone else.

For all of the risk factors listed above, there is now drug treatment available. Some may see this as a breakthrough in medical science. Some may worry that this absolves individuals of responsibility to live healthily. Others may suggest that architects, town planners and government have a far greater potential for impact by influencing living conditions.

What is not in doubt for a growing number of these conditions is that drug treatment, as analysed by cost per QALY, is cost-effective. Indeed, the National Institute for Health and Care Excellence (NICE) has just decided that an additional 4 million people should take cholesterol-lowering medication (2014). As +RCGP headquarters have pointed out, significant additional investment in general practice would be required (Baker, 2014) to deliver this objective.

Such a recommendation obliges large numbers of people with no physical illness to consult their GP regularly as if they already had a chronic disease. The only illness these people have is the fear of illness manufactured by drug companies, special interest groups, journalists, health economists and politicians who fail to make available to general practice the resources needed to undertake this massive extra work.

Project Management Triangle


There is little doubt that GPs have the skills and position within their communities to fulfil a variety of different functions. As costs rise, society must consider how it wants to use and pay for such a scarce resource. Remember the three parameters of the Project Management Triangle (, 2014) or Weale's Inconsistent Triad of Healthcare (1998): if the price of healthcare is to be controlled, society must choose between speed/access/convenience and scope/quality; we cannot have all three!

Refusing to make choices will result in the ill (group 1 above) having to compete for resources - the so-called Patient Paradox (McCartney, 2012). For the options presented above, serious consideration should be given to whether 9 years of medical training is really needed in every case, or whether individuals and communities could reasonably be expected to shoulder more risk and responsibility.

Friday 18 July 2014

2004 UK GP contract

The last time morale in general practice hit a low point was prior to the 2004 contract, which served to turn the profession around.

What were the two main planks of the 2004 contract?

  1. Out of hours cover
    GPs were given the option to relinquish responsibility for treating their patients after 6.30pm, before 8am and at weekends. For the almost 70% of the week that falls outside of these hours, GPs had each been paid £6,000 per year.
    Bizarrely, society was surprised that attempts to provide an alternative out of hours service for the same price resulted either in overspend or a less satisfactory service. Too late, the value of a service that had been taken for granted was understood.
  2. Performance-related pay
    In a massive experiment, a large proportion of GP pay was tied to successful surrogate treatment outcomes, widely agreed then to represent good Medicine. As promised, the bean counters made this tougher and tougher, adding as they did so more and more controversial measures (such as inflicting questionnaires on people suffering nervous breakdown, interrogating many about their memory and men about their erections).
    GPs persuaded government that new money would be required to employ staff to carry out this extra work. In the event, many GPs chose to work harder rather than take on so many extra staff.
    The vast majority of GPs rose to the challenge, hit the new targets and were rewarded as promised. We should be proud that to make this happen, some GPs chose to work harder and achieve better income.
The 2004 deal has since been described as generous, but it encouraged a generation of doctors to stay in UK general practice.

As general practice faces another crisis, how can we learn from 2004 to find solutions?
  1. Value appropriately those services best delivered by general practice before accepting less satisfactory substitutes
  2. Resource primary care adequately for the work required of it, without imposing arbitrary restrictions on how that work is delivered. Or, conversely, employ all primary care staff centrally and set their salaries directly (and accept the consequent increase in costs and reduction in productivity).

Monday 16 June 2014

Response to charging RCGP members for access to ePortfolio

We were dismayed to  read the announcement that access to the Revalidation ePortfolio would no longer be free for members of College. Currently, this is a uniquely tangible benefit which has helped to encourage many to maintain their membership.

It may make a lot of sense for RCGP and Clarity Informatics to join forces in this way. However, very sadly, the deal announced (free for the first 4 years then 25% discount) will not be sufficient to deter many from cancelling their College membership.

Quite apart from the personal financial cost, this will increase the administrative burden on every member by requiring them to enter into a separate contract with Clarity.

RCGP should be able to negotiate with Clarity to provide access for each member for considerably less than £50. Their administrative costs would be lower if nothing else.

The ability to access both the Revalidation and Trainee ePortfolios using RCGP website login details is very convenient. We would urge College to restore universal access to members to such products and maintain this advantage.

We do hope RCGP will revisit this regrettable decision as a matter of urgency. College should be able negotiate with Clarity to get a sufficiently good deal to allow the use of a proportion of the membership fee to cover the cost so that it continues to remain free to members.

If anyone reading this agrees, please indicate your support by signing the ePetition.

** Update **

Interim response from Dr Helen Stokes-Lampard (RCGP Treasurer) on 1 July 2014

Whilst the 'official response' to you will follow in a week or so John, for the avoidance of doubt consider this an informal reply... it was I that insisted that we make it very clear to Council and give Council at lot of information and the chance to comment on the merger proposal (but without compromising the commercial sensitivity of it all), as this was a Trustee item that had been given due consideration and due diligence  intermittently over 18months, but we could see that some members might misunderstand the reasons and the positive side to the whole thing. As you know I am a firm believer that honesty and openness are the best policy, particularly for potentially sensitive issues. 
Clearly not every item or decision Trustees or Council makes can be tested on the entire membership - that’s what we use our delegated bodies/committees for: Trustee Board includes 4 non officer GPs (as well as myself, the Hon Sec, Chair and Chair of Trustee Board) so there were 8 of us giving a GP viewpoint throughout (minutes of all meetings are provided to Council but I appreciate that you are not yet on Council - looking forward to you joining in Nov), and all the concerns raised now have been deliberated previously and I hope that subsequent communications have allayed fears and provided all information necessary... Happy to discuss in person in due course.

** Update **

 Response from Dr Maureen Baker (Chair of RCGP Council) on 11 July 2014

Further to Helen Stokes-Lampard’s email of 30 June , we promised to get back to you once the College’s Leadership Team had discussed your concerns over the decision to partner with Clarity Informatics in developing a new Revalidation ePortfolio (ReP).

The meeting took place this morning, please be assured that all the issues outlined by you and other colleagues in your letter and petition were given considerable time and attention.

We know you are particularly concerned that members were not consulted over this. Unfortunately, we are unable to consult our members on every issue but endeavour to act in the best interests of the RCGP membership at all times.
In line with College governance procedures, the Trustee Board was tasked with the responsibility of determining the future of the ReP. The decision – ratified by Council – followed due diligence and was taken in good faith to pre-empt significant challenges for our members, had we continued with the current resource.
The Trustee Board has been running now for over two years following a successful pilot. It was set up directly in response to concerns from Council that time was being taken up with the ‘business’ aspects of the College when it is Council’s role to set the strategic direction and policy priorities of the College.
This arrangement is working well and it enables Council to concentrate on the core functions of the College – supporting our members and improving patient care.
When we consult with our membership, it will always be on important issues affecting general practice and patients rather than on the governance, business and financial aspects of running the College. In the past year, we have run two UK-wide membership consultations - one to set our next round of policy priorities and the other on our stance regarding assisted dying.
As we have said previously, the decision to go into partnership with an external company was a very difficult one which took the Trustee Board over 18 months of deliberations. It is certainly not something that we rushed into or entered into lightly.
Despite our best efforts over the past three years, trying to constantly maintain and develop the revalidation tool in-house was becoming increasingly problematic. It was becoming more costly to run, even without the necessary improvements, and it would have become unsustainable in a very short time.
The new system will drastically reduce costs whilst enabling us to provide members with a long-term and continuously improving system.
Whilst we fully appreciate your reaction to our decision - and your disappointment that a cost will eventually be attached to a previously free membership benefit - we spent a great deal of time and effort negotiating the best deal possible and strongly believe that this will be financially advantageous for the majority of our members in the long-term.
To address the specific points in your letter about the process of transferring to Clarity, we have gone to great lengths to minimise any administrative burden on members as a result of the switchover.
Current users of the ReP will have their information transferred automatically and securely to the new system. Links and log-on facilities will be provided within the existing RCGP website and all data from ReP will be securely mapped to the relevant fields.
Work already uploaded to the RCGP Revalidation ePortfolio will be carried over to the enhanced new unified system and no work or data will be lost. Neither Clarity nor the RCGP can use the data for other purposes without permission.
Clarity has a proven track record in providing IT solutions for appraisal, and the new enhanced portfolio will incorporate the best features of our respective systems, as well as being interoperable with the RCGP’s Online Learning Environment and trainee ePortfolio.
We hope that this has addressed all your concerns and helped to reassure you.
We also hope that you will find the new system reliable, easy to use, and supportive to your needs in preparing for revalidation.
We very much value the time and effort you have all invested in providing your feedback and will use this to inform the way we handle future decisions.
As College Chair, I operate an ‘open door’ policy and hope that you will take the opportunity to use this as a way of raising any issues or concerns you may have in future.
Thank you and best wishes.

My reply 20 July 2014

Dear Maureen,

Thank you for responding to our concerns about charging RCGP members for access to the Revalidation ePortfolio. I have shared your response on my blog and with the Facebook groups which the majority of the signatories belong to.

I am particularly heartened to hear of the integration between the new Revalidation ePortfolio, the current RCGP ePortfolio and the RCGP website now and in the future. It is a credit to the Trustees that they have put together such a well thought through proposal.

However, we do still have concerns about the process that led to this decisions:

  1. No-one can disagree with reducing costs and improving service for members. As a result of this decision, could you please let us know when and by how much membership fees will reduce?
  2. We are still firmly of the belief that it would have been better for members to have been consulted early in the process of looking for a sustainable means of providing a Revalidation ePortfolio system for members. It is therefore of significant concern if the Trustee Board have authority to make such decisions unilaterally. Perhaps the terms of reference of the Trustee Board need to be revised to improve transparency and accountability and the perception that they faithfully represent the interests of members.
  3. I was pleased to learn from Helen's email, Nigel's post-Council letter and your letter to me that the Trustee Board did decide to gain ratification of this decision by Council. Could you please advise how many Council members voted in favour of this proposal? Were any other options presented to Council?
  4. Trainees are understandably now nervous about the future of their ePortfolio. Can you please advise how long the trainee ePortfolio will continue to be maintained by College? If arrangements for the trainee ePortfolio are revised, can you please provide some reassurance about how trainees and members will be consulted during that process?

Many thanks again for taking our concerns on board.

Best wishes,

Response from Dr Maureen Baker 6 August 2014

Dear John,

Thank you for such an encouraging and positive response to my last letter – and for making sure that its contents were circulated widely.

I am pleased that I have been able to allay a lot of your concerns about the College’s partnership with Clarity Informatics regarding the future of the Revalidation e-Portfolio. I will now attempt to respond to the queries raised in your latest e-mail in the same order in which you raised them.

While the move to Clarity is in part driven by the need to reduce costs, this will not result in a reduction in membership fees as we will not realise any financial benefit from the transfer during this current financial year. This was never about ‘quick wins’, but long term wisdom. In negotiating a deal that provides College members with free access for four years, followed by a substantial discount, we feel that we have acted in the best interests of our membership and secured a package that will offer most benefit to the majority of members. The money saved in the long run from this initiative will go towards supporting and promoting our charitable objectives, including the Put patients first: Back general practice campaign, as well as wider membership benefits.

I take your point that you would have liked to see wider consultation on this issue, but the remit and terms of reference for the Trustee Board are very clear. As this issue relates to the business of the College, rather than policy or clinical care, it was entirely appropriate for the decision to be taken by Trustee Board in line with due diligence and corporate governance procedures. The Trustee Board does not have to request Council ratification of their decisions but chose to on this occasion.

I attach the draft minute from June Council for your information. However, as the minutes will not be approved until our next meeting of Council in September, I would ask you not to circulate this further. The Trustee Board operates under strict guidelines on transparency and accountability and I would be more than happy for you to observe one of its meetings if you so wish, once you become a member of Council.

As you are aware there are a number of appraisal tools available on the market but we opted to go with Clarity for several reasons, including the company’s proven track record in this area; the fact that a great percentage of our members are already using the Clarity package, and because they could guarantee interoperability with other College systems – something which you welcome in your letter. We have also emphasised to members that they have the right to opt out of the Clarity arrangement and that we will respect their decision.

Finally, you raise the issue of the Trainee ePortfolio. Please rest assured that this is entirely independent of the ReP and there are no plans to change its ownership. The Trainee ePortfolio is directly linked to obtaining MRCGP and any changes affecting trainees are discussed and tested first with the RCGP Associates in Training committee, a very vocal and dynamic body which is involved in all areas of the College, including representation at Council with full voting rights.

I hope this clarifies all your outstanding issues.

We will shortly be sending out further communication to all members regarding the secure transfer of their data to the new enhanced system. A comprehensive FAQ will also be posted on the website for reference.

Thank you again taking such a close interest and for raising these issues with me.

Best wishes

Friday 23 May 2014

GP or Social worker? A historical perspective

Guest post by Bastiaan Kole

My father and grandfather were both country GPs (from 1924 to 1996). They knew patients and their extended families very well, had supported them through major life events, palliated them and delivered three generations of their babies.

People had no sense of entitlement and were not unreasonably demanding. In that setting (in a far less complicated world), they sometimes found reason to support people in all facets of their lives. They were taken seriously, respected and even had some success on the odd occasion when they did.

I, as any other GP or indeed any decent human being, listen with empathy and try to support people going through difficult life events, but never give them the illusion that we should by the first port of call or indeed can really help.

I have seen a lot of unhealthy co-dependency that started with “compassionate listening”. One often wonders who gets more out of it: the patient or the self-congratulatory doctor with a sense of purpose. It is invariably very time consuming as these problems can never be discussed in ten minutes and there is clearly some self-delusion, as what can be achieved is in reality very little. It does, however, take resources away from other patients and places an additional burden on colleagues.

In the seventies, GPs’ medical abilities were often ridiculed by specialists. GP training was in its infancy: requirement of completion of vocational training for general practice before a doctor could become a GP principal was only fully implemented in 19821. The extent of what could actually medically be done outside a hospital setting was much more limited. This, combined with the Zeitgeist of sociology, shifted emphasis in General Practice (as promulgated by the fledgling RCGP) to focussing on psychosocial causation of illness. The pendulum has defied gravity ever since.

Trying to make up in the consultation room for hefty social care and welfare cuts is exactly what David Cameron intended with his flawed 'Big Society' agenda2. Health is directly related to income and living standards3, which a healthcare service cannot influence. To take on the responsibility as a profession for fixing government failings is, to say the least, unrealistic or worse: a waste of time and resources, leading to medicalisation of unhappiness.

It will not end there, because it never does. Why indeed not police illegal migrants for the greater good4? Why not monitor radicalisation to possibly save countless lives5? Why not provide relationship counselling6? Why not monitor gambling habits7? Why not offer financial advice8? And what about making up for failings caused by underfunding of secondary care? The list is endless.

Idealism can lead to positive changes but often lacks realistic goals and pragmatism. Doctors who have clear views on the limits of their profession, will use resources responsibly, so that care for all their patients can be backed up by evidence-based healthcare interventions. Repeatedly accusing these doctors of “lacking compassion” is never going to lead to better care or better outcomes.

Such idealism will cause people, more and more, to regard their GP as a “life coach”, a role for which we are not trained, funded or equipped. I am sure the majority of GP's did not envisage such a role when they chose the profession.

It is neither viable nor responsible for GPs to act as social worker and life coach, nor to replace traditional support networks, in times of steeply rising demand and decrease in funding. The time has come for the BMA and RCGP to help the profession survive, by clearly redefining our roles as medical doctors and not pander to politicians’ continuous demands and point scoring.


1 Field S. The story of general practice postgraduate training and education. In: Lakhani M, editor. A celebration of general practice. Radcliffe Medical Press; 2003: p120
3Marmot MG, Bell R. Action on health disparities in the United States: commission on social determinants of health. JAMA 2009;301:1169–71. doi:10.1001/jama.2009.363
6 Swinford S. Midwives, GPs and registrars to help tackle family breakdown. The Daily Telegraph 23 March 2014
7 Sanju G, Gerada C. Problem gamblers in primary care: can GPs do more? Br J Gen Pract 2011;61:248–9. doi:10.3399/bjgp11X567027
8 Graham, G. Patients should get financial advice at GP surgery, watchdog says The Daily Telegraph. 28 April 2014

Monday 19 May 2014

GP Funding

As part of the national process to be elected as RCGP Council representative, I was invited to answer two questions. The second, from Lincoln GP Ian Lacy, was:
What plans should the College be developing to meet the impending financial crisis in the NHS, which will provoke political pressure to new methods of funding – including perhaps partial payment and the growth of health insurance?
 This was my answer:
The interim report of the Commission on the Future of Health and Social Care in England (set up by The King's Fund may provide a useful starting point, suggesting, as Dr Lacy does, user charges and other private funding streams.

Optimise value
The first priority, however, within the context of finite resources, is for GPs to focus on that which they uniquely can add the most value. We should start, therefore, by being explicit about those conditions which absolutely require medical intervention, in contrast to those which are self-limiting or which can effectively be managed without medical skills by other sections of society.

Quality assurance
Given that additional funding is likely nevertheless to be necessary, College should have an important role in anticipating the effect of any new funding model on quality GP care. The test for any new funding model should include whether it will:

  • improve access for those whose needs can only be met by medical treatment
  • not disadvantage the less affluent
  • result in better health outcomes
  • not be too costly to administer

Any new model must be compared against projections of how the current system will operate in the face of growing demand, at risk of failing the first three criteria above.

I am not aware of any good evidence that flat access charges meet any of these criteria. In terms of charges, College should seek evidence of benefit of means-tested charges for:

  • GP appointments
  • GP home visits
  • GP services (including referrals)

and prescription charges for:

  • medication available over the counter for the normally well
  • non-drug items
  • medication agreed to be low-priority for commissioning

Careful consideration should be given to the possible benefits of such charges on sharing responsibility for conserving NHS resources not only with patients but also families, communities, employers and schools, third sector organisations, local authorities and other statutory bodies.

Charges relating to the management of chronic disease are likely to be counter-productive.

Partial payment and health insurance
Health insurance has traditionally been seen as a way to relieve pressure on NHS services. However, primary care in the UK generally receives no fees from the insured and often has to do additional work, as referral thresholds are lower. Furthermore, although additional funding sources are welcome, private patients still call upon the same finite pool of medical staff. Last - but not least - we see in the US a salutary lesson of the inflationary effect of health insurance on demand for healthcare.

College may therefore have a role in assessing and planning ways to mitigate the opportunity costs of such systems so that the less privileged with medical needs are not disadvantaged.

Most but not all RCGP members currently choose to work within the NHS, offering services free at the point of use. College must, however, support all of its members and work in partnership with GPC without the prejudice of party political ideology to develop options to improve funding and working conditions in general practice in order to maintain the quality of the care, thus strengthening the hand of those who negotiate on our behalf.

Members can  vote at by noon on Friday 30 May 2014. My original election statement can be found here.

Seven day GP opening

As part of the national process to be elected as RCGP Council representative, I was invited to answer two questions. The first, from Bristol GP +Terry Kemple, was:
Should the RCGP “Put Patients First” by encouraging its members to provide a seven-days–a-week service of face-to-face appointments with a GP for non-urgent problems?  In summary, should the RCGP promote Saturday and Sunday opening of GP surgeries?
 This was my answer:
On the face of it, seven-day-a-week opening could benefit general practice by enabling us to make maximal use of our premises while improving access for patients.

Firstly, however, we need to be certain that such a service is used by those with medical needs for whom attending during the working day is difficult. The partly-booked Saturday morning surgery attended by those not in regular employment will be familiar to many members. We also need to take care that such a service does not result in the diversion of resources from those with greatest needs.

The next sticking point will be the identification of staff willing to work at the weekend, mindful of the potential impact on their families. It is becoming harder to recruit GPs in hours, let alone at the weekend.

Having said all this, the Department of Health currently seems determined to introduce seven day working. After making the risks clear, College should therefore work with the Department of Health and other stakeholders to minimise the harms to colleagues and vulnerable patients.

Members can  vote at by noon on Friday 30 May 2014. My original election statement can be found here.

Monday 12 May 2014

Acute respiratory infections

(latest update 14 May 2014)
GPs must meet the healthcare needs of a population of patients, not just those who currently succeed in making contact. It is therefore vital that we give colleagues, patients, carers and policy makers the right advice to ensure that those likely to benefit from medical treatment can and do consult us in a timely fashion.

A significant burden of illness in the community is self-limiting, for which treatment by doctors adds little and risks harm.


Acute respiratory infections are extremely common. For example, adults have up to 2-4 colds per year and children up to 121. If every one of a GP’s 2,000 patients attended just 3 times per year with an acute respiratory infection, 6,000 appointments would be needed. This alone would fully occupy a full time GP, who would have to offer 26 appointments per day (assuming 230 working days per year). This would deny anyone the opportunity to consult their GP about any medical concerns for which medical treatment is actually likely to be necessary. Consultation rates are already rising again from a low of 50.2 visits per 1000 person-years in 20042.

Furthermore, 15-30% of patients consult more than once during each acute respiratory infection2. Anecdotally, the first presentation may be within hours of the onset of symptoms and they may additionally consult other healthcare providers such as walk-in centres and Accident and Emergency departments. The urgency and frequency of this demand places the healthcare system under enormous pressure.

Antibiotic prescribing

Presenting to a doctor with a self-limiting acute respiratory infection increases the risk of prescription of antibiotics (often requested by patients when the doctor is unable to reassure them), probably more than any other factor3. This poses risk to the individual patient, who is more likely to experience side effects than benefit, and to the population by encouraging antibiotic resistance.

Overtreatment and illness behaviour

In addition, each prescription for antibiotics encourages friends and family members to attend, and earlier, more frequent attendance in future. Some doctors perceive writing a prescription for an antibiotic to be time-saving: nothing could be further from the truth. For example, of ten people who are prescribed antibiotics for a sore throat, one of them will return within a year with a subsequent sore throat, when they otherwise would not have.4

Even being prepared to negotiate can be dangerous: the gambling industry is testament to the fact that an unpredictable reward can reinforce behaviour more strongly than anything (variable reinforcement operant conditioning)6. Furthermore, the clinician who has appropriately resisted prescribing antibiotics risks a complaint when another clinician is subsequently consulted and acquiesces.

Indeed, if we did have an effective treatment for these illnesses, there would by no means be capacity for GPs to deliver it. This was demonstrated during the 2009 “Swine Flu” pandemic, in which Tamiflu (oseltamivir) was made available in the UK through a national telephone helpline. It has since transpired that the benefits of Tamiflu do not outweigh its risks8. Elaborate isolation measures were also put in place, which, at best, only slowed spread. 

Treatable acute respiratory infections

The number of acute respiratory infections for which medical treatment is essential to avert long term disability or death is small and includes pneumonia, epiglottitis and complications such as quinsy, mastoiditis9, dehydration and sepsis.

Unfortunately, published literature does not yet support the reliable prediction of pneumonia10 and complications of sore throat11 by symptoms and signs alone. We must therefore advise patients to watch out for symptoms suggestive of more severe illness rather than presenting earlier with less specific symptoms (“safety-netting”12).

Symptoms which would merit immediate assessment (“red flag” symptoms) would therefore include:

  • reduced consciousness
  • cold peripheries
  • mottled skin
  • cyanosis
  • anuria
Symptoms strongly suggestive of a need for intervention (“amber flag” symptoms) would include:
  • breathlessness
  • haemoptysis
  • pleuritic chest pain
Less urgent assessment should be considered for symptoms that do not resolve within a timeframe normal for viral illnesses (“green flag” symptoms):
  • cough for more than four weeks
  • earache for more than eight days
  • sore throat for more than seven days13
  • fever for more than five days14
Those that are at highest risk of such complications are the least affluent with the most unmet social needs. This group seem to present readily15. However, if they present without symptoms of the above serious conditions, those that are seriously unwell will be lost amongst the majority with self-limiting illness. Tragically, these will be the first to die.

In reality, the intervention that will have the biggest impact on improving life expectancy, especially in this group, is improving their living conditions. This responsibility must be placed firmly where it belongs: with society and the government.

The remainder of uncomplicated conditions (including acute otitis media, conjunctivitis16 17, pharyngitis, tonsillitis, laryngitis, rhinitis, sinusitis, tracheitis and acute bronchitis18), will resolve spontaneously with no long term sequelae.

This has to be set against the number of medical conditions which are likely to benefit from treatment, such as cancer, heart disease, diabetes mellitus and thyroid disease to name just a few, for which timely access to healthcare professionals is vital: too soon and the symptoms will be too non-specific for targeted investigation; too late and long term complications or reduced life expectancy may be unavoidable.


Desires to improve various health outcomes, whether it be earlier diagnosis of cancer and therefore improved survival or reduce unplanned admission or even reduce infant mortality have been used to justify blanket measures to speed access to healthcare. Unfortunately, these have been implemented without any evidence that they will actually benefit the groups in question, or whether it will actually be even harder for them to compete with those with self-limiting illnesses.

Workforce planning

As the number of GPs is more likely to reduce than increase due to retirement, emigration and insufficient training, it is therefore imperative that patients and their carers (particularly professional carers such as in childcare settings) are confident in diagnosing and managing common acute respiratory infections, with the assistance of community pharmacists.

Health literacy

GPs could support this by setting up training programmes (Ofsted would be well placed to make this obligatory for schools and nurseries). Community volunteers (“Health Champions”19) could help to cascade and support this training. Minor ailments schemes should be commissioned to enable pharmacists to dispense over-the-counter medication for the relief of symptoms free of charge to those exempt from prescription charges.

With these measures in place, consulting healthcare professionals with symptoms of uncomplicated acute respiratory tract infections should be discouraged. Anything which encourages such behaviour, such as prescribing for acute respiratory tract infections should also be discouraged.

Opportunity gain

If we can significantly reduce attendance for acute respiratory tract infections, the opportunity gain will be immense, allowing patients with medical conditions which are likely to benefit from medical treatment much better access to their doctors.


Further work

  • Systematic review of the literature focussing on predictive value of symptoms
  • Evidence to guide safety netting

For Local Authorities

  • Community Health Champion schemes
  • Housing

For National government

  • Accept responsibility for life expectancy (a societal/economic, not a healthcare issue)
  • Understand that access to healthcare must be targeted to exclude self-limiting illnesses


  • Endorse this document
  • Accredit training in diagnosing and managing common self-limiting illness for nursery and school staff

For Ofsted

  • Ensure one member of staff with self-limiting illness training at each nursery and school is on duty at all times

For CCGs

  • Commission minor ailments schemes

For GPs and other healthcare professionals

  • Address prescribing for self-limiting illness - possible audit area.

Symptom summary

Red flags

(consider urgent assessment for immediate treatment or admission)
  • reduced consciousness
  • cold peripheries
  • mottled skin
  • cyanosis
  • anuria

Amber flags

(consider assessment for treatment; urgency depends upon severity)
  • more difficulty breathing than usual
  • haemoptysis
  • pleuritic chest pain

Green flags

(symptoms typical of self-limiting respiratory infections; consider assessment for treatment if last longer than normal)
  • cough for up to four weeks
  • earache for up to eight days
  • sore throat for up to seven days
  • fever for up to one week

Yellow flags

(factors known to increase consultation and therefore antibiotic treatment for self-limiting respiratory infections)
  • previous treatment of patient for respiratory infection
  • treatment of contact for respiratory infection

Black flags

(features not covered by this review)
  • Any symptom not mentioned here
  • COPD
  • Bronchiectasis


1Colin Tidy (2012). Upper Respiratory Infections - Coryza | Doctor | Retrieved April 6, 2014, from
2Stanton N, Francis NA, Butler CC. Reducing uncertainty in managing respiratory tract infections in primary care. Br J Gen Pract 2010;60:e466–75. doi:10.3399/bjgp10X544104
3Fleming DM, Ross AM, Cross KW, et al. The reducing incidence of respiratory tract infection and its relation to antibiotic prescribing. Br J Gen Pract 2003;53:778–83
4Marshall T. Reducing unnecessary consultation - a case of NNNT? Bandolier 1997;44-4
5Kendall SB. Preference for intermittent reinforcement. J Exp Anal Behav 1974;21:463–73. doi:10.1901/jeab.1974.21-463
6Sparkman RB. The Art of Manipulation. Knopf Doubleday Publishing Group 1979
7Michiels B, Van Puyenbroeck K, Verhoeven V, et al. The value of neuraminidase inhibitors for the prevention and treatment of seasonal influenza: a systematic review of systematic reviews. PLoS One 2013;8:e60348. doi:10.1371/journal.pone.0060348
8Jefferson T, Jones MA, Doshi P, et al. Regulatory information on trials of oseltamivir (Tamiflu) and zanamivir (Relenza) for influenza in adults and children. 2014. (accessed 11 Apr 2014)
9NICE. CG69 Respiratory tract infections: NICE guideline. 2008
10Stanton N, Francis NA, Butler CC. Reducing uncertainty in managing respiratory tract infections in primary care. Br J Gen Pract 2010;60:e466–75. doi:10.3399/bjgp10X544104
11Little P, Stuart B, Hobbs FDR, et al. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ 2013;347:f6867. doi:10.1136/bmj.f6867
12Neighbour R. The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style. Radcliffe Publishing 2005
13Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013;347:f7027. doi:10.1136/bmj.f7027
14NICE. CG160 Feverish illness in children: NICE guideline. 2013
15Carr-Hill RA, Rice N, Roland M. Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices. BMJ 1996;312:1008–12. doi:10.1136/bmj.312.7037.1008
16Rose P. Management strategies for acute infective conjunctivitis in primary care: a systematic review. Expert Opin Pharmacother 2007;8:1903–21. doi:10.1517/14656566.8.12.1903
17Sheikh A, Hurwitz B. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane database Syst Rev 2006;:CD001211. doi:10.1002/14651858.CD001211.pub2
18Little P, Stuart B, Moore M, et al. Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis 2013;13:123–9. doi:10.1016/S1473-3099(12)70300-6
19Altogether Better. Health Champions. 2014. (accessed 6 Apr 2014)