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.

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