Notes from RCGP Council meeting 21 November 2015

Unfortunately, I was unable to attend this Council meeting for family reasons.

However, I am pleased to say that Council approved the ongoing work of the group working to improve transparency within College. In line with Council's previous directions:
- We have agreed a process by which draft Council papers will be designated as suitable for sharing with the whole membership.
- We will establish a mechanism for such sharing, complete with any necessary safeguards.
- We will recommend a Twitter stream from Council meetings.

Stand and deliver: your data or your health!

Dr +Nicola Waldman writes to +Which? 

As a GP, I have significant concerns around the practicalities of medical record sharing. Which? ran an article concluding that the NHS should learn from Apple and Google to “modernise” its records systems. However, I fear they overlooked some important details, and have shared my concerns with the editor.

1. Much NHS data is already managed by private firms
   6 in 10 Which? members surveyed are not happy for their health data to be shared with private firms. I wonder how many of the public are aware that GPs use clinical IT systems owned and managed by private firms to keep their records? The distinction between what data is held within the NHS and what is held by private companies is not one I think is commonly understood.
   
2. Pharmacy2U is 20% owned by a GP IT system provider
   EMIS is one of the biggest suppliers of IT systems to GP practices. Pharmacy2U was recently fined for selling patient data. Pharmacy2U is in fact 20% owned by EMIS. Not only that, but the CEO of EMIS, Chris Spencer is also a non-executive director of Pharmacy2U. Private firms already hold vast amounts of patient data. Can we really trust them, after the Pharmacy2U fiasco?
   
3. HSCIC cannot process opt-outs
   When the care.data programme was initially rolled out, patients were given the option of “Opting out” of sharing their data. GP practices added a code to the patient’s record which was meant to ensure their data was not shared. Yet the chair of the HSCIC later admitted that the organisation was unable to process the objections, so data could have been shared without consent. If this organisation is unable to manage patient’s data in line with their wishes, what hope is there that those who receive the data will be able to? Thankfully, for this reason, the programme was stalled.
   
4. Billions have already been wasted on the goal of NHS IT integration
   Finally, we must not forget the debacle of the National Programme for IT, later known as Connecting For Health. The ambitious IT programme cost billions. It was meant to link all the different IT systems within the NHS together, so the shambles of such situations you rightly point out, where medical records within one part of the NHS are not visible to another became a thing of the past.
   Yet it failed. Prestigious IT companies walked away from their contracts. They could not make the idea a reality. Given that in very recent years, despite eye-watering amounts of money and the best brains around working on the project, it was not found to be possible, should we again pursue this goal?

I agree with the ideal that patients should have a smooth journey through the NHS system with every part of it communicating with the other and with minimal risk of data breaches. I am just not sure that this is feasible. And I am very sure that patients would not understand who holds their data, in what circumstances it would be shared and for what purposes.

What is a "tick box exercise?"

I often hear criticism of assessment processes as being "tick box exercises". One way to respond to such feedback is for assessors to replace the actual tick box with one or more boxes in which one must record a descriptive account, often to record reflection.

Is this an appropriate response to what critics actually mean by "tick box exercises?" What do they mean?

I suspect the phrase "tick box exercises" is actually often short hand for mandatory, time consuming data collection exercises of little or no value.

Therefore, replacing the tick box with space for a fuller, descriptive response in reality exacerbates the problem, resulting in an even more time consuming exercise; whilst reflection may be documented, it may be at the expense of a more meaningful, less constrained discussion between colleagues working together to improve each other's performance.

Take GP training for example. Experienced GP trainers report being able to predict within 2 weeks whether their trainee will complete their training successfully within the usual time frame. If there are concerns, space to record them in evidence can be helpful. However, if there are no concerns, perhaps all we need is a single tick box at the two week mark!

Further reading: Edward Ng: Quality assessments in general practice—have we gone too far?

Instant cures, shared experience and versatility

I was inspired by the #whyGP project to consider why I chose general practice. Here are just a few of my reasons.

Instant cures

What could be more satisfying than curing someone in the space of ten minutes? I was inspired to become a GP after observing the healing power of the GP consultation itself.

I had this epiphany in Woolwich whilst sitting in with GP Simon Lundy. A mother was worried about the health of her child. Dr Lundy expertly reassured her that it was a self-limiting illness which required no specific treatment and from which the child would make a full recovery. Her relief was palpable.

Such consultations occur several times a day for every GP. Years of training and experience and first class communication skills allow a rapid assessment, a diagnosis based on probability, reassurance or simple treatment and safety-netting in case of a less common cause. This is not “fobbing off” or “missed diagnosis” but pragmatic, family medicine that achieves personalised healthcare with unrivalled cost-effectiveness. This approach should be celebrated: the NHS relies upon it.

Shared experience

I really value being a part of the same community as my patients. Some colleagues prefer not to live in the practice area lest patients consult them on the street. However, I like that sense of connection with my patients: whether it be simply experiencing the same traffic, power cut or weather event; whether it be having enjoyed the same local festival; whether it, sadly, be a road traffic accident or some other tragedy; or whether (in my case) it be an opportunity for patients to provide feedback on my choral singing!

All of these shared experiences help to build rapport and mutual understanding and respect, putting patients’ health firmly into their social context.

My memory of working in hospital is that special effort is needed to understand a patient’s social context and to maintain their dignity within that sanitised, other-worldly environment.

In general practice, patients often apologise for attending in their work clothes. Of course, apology is absolutely not needed, as it helps to bring to the fore the person rather than the illness.

Understanding the social context is of course vital in any walk of life, but is something that is particularly important in general practice, even if it is not for us to change social factors.

Partnership

As a GP registrar, I came to enjoy the sophisticated interactions with my patients. They treated me as their advisor, albeit one whose advice occasionally required me to write a prescription. They did not come like a car to be “fixed” but to work in partnership to understand their health concerns and needs, drawing from my medical expertise.

Doctors have tended to accept blame as a legitimate way of allowing patients to cope. If media, charities, regulators and courts encourage complaints and a culture of blame and punishment, we risk losing this precious partnership. Let us work together to build on this collaboration which allows GPs to help so many patients.

Pace

One of the things I really enjoy about general practice is the pace. Every 10 minutes, a new patient walks through my door with a new set of concerns. Beyond clues in their records, I have no idea what they might want to discuss with me. They might have severe depression and need an emergency referral, or they might have just discovered their xiphisternum and need reassurance that it is normal.

I am not a specialist. I am proud to be an expert generalist. That means, amongst other things, that I am expert in treating common conditions, basic treatment of less common conditions, recognition of what is normal as opposed to what might need further investigation, and considering how different aspects of a person’s health might interact.

This variety and pace is a marvellous challenge and keeps one on one’s toes throughout the working day or even career!

There are opportunities to develop special interests. There are also strong arguments that appointments should be longer than 10 minutes and perhaps even that there should be some kind of triage process (to ensure, for example, that some issues are dealt with by colleagues). However, I am glad to say that the pace and variety of work in general practice is in no danger!

Flat hierarchy

When I was sitting in with Dr Lundy in 1999, the partnership model of general practice was at its height. By and large, if a practice wanted a new GP, they had to take them on as a partner, a fellow principal with whom patients could register with for their GP care.

Clearly, each partner brought different skills to the team, whether it be seniority, expertise in a particular clinical area or responsibility for a particular area of practice management. However, once established in a partnership, each partner within each practice drew an equal share of practice profits (with the exception of seniority payments) and had an equal vote in practice decisions.

Thus, just 3 years after leaving medical school, there was a relatively flat hierarchy and a culture of respect for differing opinions and skills. Nowadays, many GPs choose a salaried contract over partnership. Nevertheless, the culture of respect remains strong in most practices and is something that, as a profession, we should prize.

Versatility

My GP trainer said he would equip me to practise independently anywhere in the UK.

Wow!

It seemed a tall order at the time, but that is indeed what he did. In reality, with the skills I learned, I could practise just about anywhere in the English speaking world (with the exception of the USA). With NHS contracts about to be revised, that is highly comforting.

However, this versatility is not confined to political geography. There are so many opportunities for UK GPs, trained as they are to an increasingly high standard.

I could work in a town (as a I have). I could work in a rural setting (as I have for many years). I could work in a city (as I currently do). I could work at a walk-in centre. I could direct a walk-in centre (as I do). I could work training tomorrow’s GPs (as I do). I could work as a locum GP, under contract as a salaried GP or in partnership. I could work out of hours (as I have done regularly). I could work with a hospital specialist as a clinical assistant (as I have done). I can undertake minor surgery and joint injections. I could represent my practice to commissioners (as I have). I could work with colleagues to bid to provide new services (as I am doing). I could represent GP colleagues within RCGP regionally (as I have) and nationally (as I do).

These are just a few examples of the opportunities available to GPs. Other GPs work as researchers, as occupational health physicians, in the military, on cruise ships, in Public Health, as politicians … the list is almost limitless!

The medical, interpersonal and management skills honed through GP training are second to none. The only uncertainty at the current time is who pays us.

If this sounds a little like a CV, perhaps it is: my family wish to move and I am looking for a new practice. Just as well I can practise almost anywhere in the English-speaking world!

Originally published on WhyGP.uk.

Is it time for all GPs to resign from the NHS contract?

+Pulse Today invited me to Pulse Live Liverpool to argue that it is now time for all GPs to resign from the NHS contract. Highlights of my speech can be heard in the video below or read on Pulse's website. It was reported on the front page of the +Sunday Express on 4 October 2015.

Notes from RCGP Council Meeting 18 September 2015

#OpenRCGP

I reported that progress is being made on "balancing transparency."

• We are working on a procedure for classifying as public as many Council papers (agendas, minutes, reports and background papers) as possible.
• We are likely to recommend "live" tweeting from Council meetings with a delay.

We anticipate bringing these proposals to Council in November. We will continue to explore the following strands:

• Practicalities and costs of publishing on RCGP intranet for members to be able to access papers classified as public. (It is felt that it would be confusing to put this material on the public-facing website).
• The demand for and practicalities of publication of other material (such as committee papers).
  ** If this is something you would like to see, or if you know how other organisations do this, please leave a comment below **

Discussion items

Council spent considerable time discussing a response to government proposals for seven day working. It was emphasised that "spreading the jam" more thinly to provide routine care seven days a week would jeopardise urgent care services, when the priority must be to reverse years of underfunding of out of hours care. Patient rightly expect high quality, safe care: providing a universal seven day service will not achieve this.

In similar vein, Council was dismayed at the latest DDRB recommendations on junior doctor pay, particularly the removal of the GP training supplement. Chair of Council Maureen Baker had written to Jeremy Hunt expressing concern in August and received some reassurances; she will now write to him again "saying that it is urgent and imperative that a clear message is given to junior doctors that they will not be financially disadvantaged by choosing to enter general practice training".

It was noted that contract negotiations are the remit of the BMA, which responded to the news on 15 September and issued further explanation of its position on 17 September.

We also discussed the Roland Commission report on the Primary Care Workforce, which acknowledges the need for investment in primary care. It was noted that Physicians Associates (who are not independent and require supervision by a GP) are not a substitute for GPs, although they may have a helpful role to play. The assertion that email consultations should become routine was questioned.

#ImInWorkJeremy: which hospitals will you close?

Some seem perplexed that junior doctors and other staff are joining the #ImInWorkJeremy twitterstorm in solidarity with their consultant colleagues. I have also seen the suggestion that Hunt was respectful to doctors during his Radio 4 interview.

Make no mistake, consultants are working this weekend also. They are obliged to. In fact, many of the current generation of consultants are the same individuals that were exploited as junior doctors before the 1998 New Deal that put an end to unsafe 100 hour working weeks.

Indeed, it is a product of the New Deal and the European Working Time Directive which necessitates consultants personally to undertake a greater share of the work of their teams than ever before.

These dedicated doctors need no lessons on vocation and professionalism, and it was Hunt's implied slur against these traits that I suspect has caused the outrage.

Hunt suggested that 6000 deaths per year could be prevented by changing working patterns.

Firstly, this number seems to have been derived from unpublished data which cannot be scrutinised.

Secondly, the phenomenon of a higher death rate at the weekend extends even to the US, where working patterns are very different.

Thirdly, if we divert even more consultants to work at the weekend instead of the week, weekday services will inevitably decline and harm will ensue.

Fourthly, as the BMA point out, given that consultants are already working at the weekend, what is really needed to make 7 day work a reality is for all support services to be ramped up overnight and at weekend - from radiographers and lab workers to social workers, care agencies and public transport.

Sorry, Mr Hunt, we do not have such a 24 hour society. Citizens have a right to a family life.

Given the woolly statistics, I do not believe the drive for 7 day working has anything to do with patient safety. If it were, it would be piloted and properly evaluated for the inevitable risks to patient safety.

No, this is all about efficiency. The only way to pay for these changes will be to close hospitals.

WHICH HOSPITALS WILL YOU CLOSE, MR HUNT?

Seeing patients. Drinking coffee. Storing your comments in a box behind me #ImInWorkJeremy pic.twitter.com/WHzJEfl5sB

— Dr Keith Grimes (@keithgrimes) July 18, 2015

A further blueprint for primary care

I was interested to hear Jeremy Hunt announce on Radio 4 his intention to review the terms and conditions of GPs. I feel this is overdue. Much has been written about the crisis of recruitment and expectation faced by GPs, who, being the most efficient part of the NHS (90% of NHS work done by primary care for less than 8% of the total funding), are most able to drive some of the £22bn efficiency savings demanded by 2020.

Being a GP in the UK is a uniquely fulfilling occupation. However, the frustrations and challenges are beginning to threaten a truly rewarding career. So what might bring general practice back to being an awesome career choice?

In mulling it over, I considered if I were to be in charge of the nation’s health policy and legislation, what would reduce the frustrations and safeguard the viability of general practice? From a conversations with colleagues emerged the following ideas.

Idea 1. Produce and continuously monitor the activity levels of GPs –  both demand and access.

This would allow for effective planning rather than rhetoric. RCGP has called for this in its blueprint for the new deal for GP in England.

Idea 2. Increase remuneration and supply of GPs to enable them to have smaller patient lists to be able to maintain that activity level.

In the past 5 years activity has increased by over 40 million consultations per year over the past 4 years. However primary care has seen a similar period reduction in funding from 11% to about 8% of the NHS annual budget. In short a ~13% increase in work for a ~28% reduction in funding.

Idea 3. Make changes to control activity:

3.1. Allow only the prescription of prescription-only (POM) item on NHS prescriptions

3.1.1 Prohibit pharmacists from selling treatments without a prescription (“over the counter”) at a higher price than with a private prescription

3.1.2 Re-evaluate the current criteria for ‘free’ prescription entitlement especially with regards to chronic health conditions.

3.1.3 Create a national formulary for use by the NHS.

A significant portion of resources both in terms of finance and time can be spent on prescribing issues with significant variation in geography, practice and ethos. Standardising and making these efforts more equitable would solidify the aims of treatment in line with the ethos of fair treatment for all. Additionally a national formulary may help to prevent stock sourcing issues currently facing many GPs, pharmacist and subsequently patients.

3.2. Forbid priority to be given on the basis of a referral from NHS staff for any service or treatment not agreed with GPC

3.3. Forbid advising people to consult their GP except if they are ill, believe themselves to be unwell, or for any reason agreed by GPC

3.4. Contract separately medical treatment of those with no illness

GPs are primarily contracted to treat the ill and those who believe themselves to be unwell. However, there is currently nothing to stop anyone publicly advising people to attend their GP for any one of a variety of reasons, whether that be the treatment of self-limiting conditions, cosmetic concerns, the prescription of drugs to the well, marginally to extend life expectancy (statins) or even the prescription of boilers. These may or may not be worthwhile, but undertaking this work without adequate resources distracts GPs from those who need them most – the ill.

3.5. Allow GPs only to consult in approved premises except when treating those who are housebound and in the terminal phase of an illness.

Home visits and community based resources are both a privilege and a finite resource. They are not a right for convenience particularly with increasing workload pressures and reducing resources. Contractual changes as above would support clinicians offering equitable and appropriate care as already functioning in some areas such as South Staffordshire LMC visiting guidelines.

3.6 Remove fitness certification from the GP role.

It is important to provide equitable treatment of patients by appropriately trained clinicians. GPs have a fundamental conflict of interest when it comes to fitness certification. Their duty is to act in the best interests of their patients. This makes it both difficult and uncommon for a GP to challenge a patient’s belief that they are medically not fit for work. Pilots for this are already underway. Remove this duty and free up GP time whilst opening up the possibility of a fairer assessment process.

Idea 4. Instead of capitation-based funding, offer activity-based funding to those GPs with a minimum list size determined on the basis of predicted need.

Currently general medical services (contract on how primary care is offered) is enumerated at an average of £136 per patient per year- less than a standard Sky TV package. This funding model needs an evaluation given the significant increase in health needs by an ageing population with more chronic disease issues. Many acknowledge the historical advantage of capitation funding in giving GPs an incentive to provide only necessary treatment. However, GPs have now completely lost control of demand. Activity-based funding would give an incentive to every taxpayer to encourage fair use of GP services. Indeed LMC Conference on 22 May 2015 passed a motion supporting exactly this change.

Idea 5. Allow GPs to be covered by Crown Indemnity/ reimbursement of indemnity.

A growing issue pushing many GPs away from working particularly in out of hours services and deprived areas is the rapidly increasing costs of indemnity cover. Incorporating crown Indemnity or establishing a way to reduce costs (something even outstanding CQC banding can not help with) would facilitate more GPs not being priced out of working in such valuable areas. Precedent may be set with the incoming primary and acute care systems (PACS) as suggested by the Five Year Forward View. The LMC Conference voted for this proposal on 22 May 2015.

Idea 6. Amalgamate the GMC speciality and GP registers.

This would allow GPs to be recognised for sub-specialising and aid GPs to be viewed as equitable in status as specialist consultants as their training currently allows. This may help to address some of the issues noted in the recent BMA survey (see below) which Government policy changes will not.

Fig.1. GP trainees’ responses when asked why they didn’t choose general practice as their specialty. (BMJ Careers 2015)

Idea 7. Exclude General Practice from the NHS.

A severe idea with growing support. General Practice as a gatekeeper is central to the NHS. However, unless the GP contract is adjusted to include the ideas suggested above, General Practice and possibly also the NHS will fail. British GPs have unique skills in managing risk pragmatically across an extraordinarily broad range of medical conditions and may have no choice but to reserve these skills for fee-paying patients and health insurers.

These are ideas which may or may not resonate with your own thoughts and obviously vary with severity as well as risks and benefits. I am not saying these all have to happen or that they are all miracles that will save both healthcare or the speciality that is general practice. However we are always asked to bring ideas to light and many of these have the possibility of significant impact at a time where the NHS and general practice are in crisis.

First published with Dr H Gandhi (+Dr Gandalf) on 23 May 2015 at eGPlearning. I note that the +Conservatives government has paid scant attention to any advice offered by GPs in their New Deal for General Practice.

Mental illness, General Practice and the GMC

+Clare Gerada tells +BBC News that levels of mental illness in GPs has become disproportionately high in recent years as a result of the unprecedented pressure they have been put under.

It is tragic that so many GPs are so unwell. This must change.

However, this also highlights the problem of stigma of mental illness among doctors. While doctors have a duty to shop to the GMC their doctor patients and unwell colleagues, stigma will persist.

I would suggest that duty should be confined only to those whom one is a current clinical colleague of.

CQC response to call for emergency measures

At least the quango that is the +Care Quality Commission has sufficient insight to be "disappointed" after the democratically accountable +Royal College of General Practitioners and +The BMA call for emergency measures (RCGP, BMA).

That insight seems so far to be rather limited. After visiting 1,100 practices, it is quite extra-ordinary that CQC thinks its approach would not be burdensome for a "well-managed" practice.

I trust Steve Field will now lead them through serious and soul-searching reflection.

It is time for our regulators to question the effectivenes of their apparently hostile stance and encouragement of burdensome bureaucracy and to ask themselves how they were allowed to get so carried away.

Colluding to collapse General Practice just might not be the best way to reduce variation in quality!

@DrJohnCosgrove John, the hostility does not come from CQC. The approach is based on co-production + shared ambition of high quality care...

— Kay Sheldon (@KayFSheldon) June 28, 2015

Notes from RCGP Council meeting 20 June 2015

The agenda for today's meeting was packed, including, I am pleased to say, a paper on transparency which I wrote with +Jonathan Leach and +Kirsty Baldwin.

#OpenRCGP discussion paper:
Balancing transparency with information security

"First of all, I would like to thank my co-authors Jonathan Leach and Kirsty Baldwin for their invaluable input, and also Officers and staff, including Paul Rees, for their enthusiastic encouragement.

"I have been receiving Council papers for over 10 years. Throughout that time, I and colleagues have had some uncertainty about how confidential individual College documents are, and therefore a frustration that we did not feel free to share them with other members.

"There are some practical details to be worked out. We are looking for feedback from Council on our proposals to allow us to continue developing these proposals

"Our proposals therefore form two main strands:

• clarity as to exactly how confidential individual documents should be
• reduce the risk of unwitting leaks
• and minimise unnecessary restriction
• this builds on good practice by groups such as the Trustee Board and the Planning and Resources Committee
• publication of Council documents
• moving from a position of sharing with members only what we are obliged to share, to sharing with members as much as possible so as to improve engagement and foster a sense of ownership commensurate with their membership fees
• builds on the decision at the Council meeting in February 2015 to publish minutes
• as part of this, our 3rd proposal is for a staff observer to Tweet from Council
• builds on Council’s views on Social Media use during Council meetings aired in September

"We would be grateful for Council’s thoughts on these proposals.

My understanding of Council rules as they stand is that I am free only to disclose my comments, hence the one-sided nature of my notes here.

"New deal for General Practice"

Jeremy Hunt had set out what he described as a new deal for General Practice the day before. I have already analysed this announcement on these pages and found it wanting. I told Council that it contained neither anything new nor a deal and that I continued to be dismayed at his apparently fixed idea that healthcare is a commodity. Indeed, his assertion that he could not change consumer expectations was particularly disappointing and he is probably referring more to an unwillingness to risk losing votes by being honest with patients about what they might reasonably expect from the NHS.

Overdiagnosis

I welcomed a paper on overdiagnosis from +Margaret Mccartney and +Julian Treadwell on behalf of the RCGP Overdiagnosis group. It proposes tests to be applied to every policy proposed by RCGP. I advised that these include a test of opportunity cost: i.e. if new work is proposed, what old work should GPs stop doing?

GP workload & fatigue

I welcomed a paper linking GP workload with patient safety. I warned that there is a fine line between making such a link and acknowledging that GP is relatively low risk, without fuelling further risk intolerance, which itself has been a major driver of pressure on GP services.

I warned that making a link to "missed and delayed diagnoses" implies a precision and urgency of diagnosis that is often not appropriate in General Practice and risks encouraging over-investigation, -diagnosis and -treatment. I recommended instead referring to "reduced quality of diagnosis" and "unacceptable delay in treatment."

Skill mix in General Practice and Primary Care

I warned that many members are nervous about proposals to increase the skill mix in General Practice. We must reassure them that we are the Royal College of General Practitioners and will put their interests first.

I advised that changing the name, remit or democratic processes of College would be a big decision and should only be considered after a full a careful consultation with the membership as a whole. Until then, the involvement of non-GPs in the democratic processes of College should be limited to observing.

New deal for General Practice?

Today, Jeremy Hunt set out his new deal for general practice that he started work on amid much fanfare only one month ago. GPs struggling to cope with the burdens of increased demand and accelerating retirements had been awaiting this eagerly. RCGP had published its Blueprint for General Practice, setting out what General Practice urgently needs. How much of this has been heeded?

Demands

This was presented as a quid pro quo: in return for investing in General Practice, GPs are asked to:

Work 12 hours per day 7 days a week

An election manifesto commitment. Still no hint as to where the resources necessary for such a change will come from. Clearly the driver here is to reduce hospital workload: one might naively suppose that resources might accordingly be diverted from hospitals to General Practice.

Undertake social prescribing

Again, no suggestion as to how a service struggling to meet its current obligation might be able to undertake such an enormous new area of work. Closer integration of health and social services and their budgets has been suggested, but does it really make sense to use up more of the scarce resource that is the General Practitioner in this way?

Have a bigger role in Public Health

Might General Practice be expected to pick up the pieces of a Public Health service underfunded by Local Authorities? How is this to be resourced?

See publication of outcomes data

In spite of CQC's much-derided experience of publishing "Intelligent Monitoring" data (remember its description of GP practices "at risk"?!), Mr Hunt seems determined to continue this approach. How this could support a "change in culture – from name and shame to learning and peer review" is not clear, although such a change in culture is long overdue.

New commitments

So what new commitments has the Secretary of State for health made today?

£7.5m to Community Pharmacists

This will be diverted FROM  the Primary Care Infrastructure Fund set up to build new GP premises.

650 new GP training places

1,000 Physicians' Associates by 2020

Physicians' Associates had already been promised, but now we have a specific number. There remains debate as to exactly what their role should be.

4,000 practice nurses, district nurses and pharmacists

There is currently a surplus of pharmacists, so presumably these will form the bulk of this 4,000. RCGP and RPS are calling for finance from NHS England to support the introduction of practice-based pharmacists. There was no confirmation of such an arrangement in this speech.

Nurses are sorely needed, but Mr Hunt has said nothing today about how they might be recruited.

Clinical staffing data

Sure, this may help workforce planning. Why ever is this data not already available? What we really need, however, is detailed GP workload data. HSCIC even stopped collecting consultation rate data in 2008. The Nuffield Trust attempted to assess GP workload: it found consultation rates to be stable but hypothesised that "non-direct patient work", which it could not measure was taking up a disproportionate amount of GP time.

New ideas

There was just one new suggestion with no specifics:

Reduce bureacracy

Old commitments

£10m for struggling practices

It seems likely that this is not a new commitment, but part of the Primary Care Infrastructure Fund.

Clearly, within a national context, £10m does not buy a lot of GP time (ca. £1,000 per typical practice, £250 per GP or less than 20p per patient). However, if this is targeted sensibly, it could save a small number of practices (perhaps 40-100).

Extend GP training by one year in some areas

This something RCGP has been calling for nationally for some time. Unfortunately, this commitment is limited to certain areas and at least part of the extra year will be spend in hospital specialties, so General Practice will not immediately feel the benefit of an extra pair of hands.

Part-time working scheme to retain GPs close to retirement

More recycled ideas included:

• 5,000 new doctors - an old promise. Where will they come from? That would require a doubling of GP training
• A "pre-GP scheme" to encourage medical students to choose General Practice which has already been running for at least a year
• A "marketing campaign" which RCGP has already started and apparently attracted 300 new recruits
• A GP returner scheme which has so far attracted just 50 GPs
• The £1bn Primary Care Infrastructure Fund - very welcome, but is a one-off fund for buildings, not GPs

Summary

In summary, Mr Hunt has a great deal on his wishlist, but will not provide General Practice with anything like the resources required to deliver it. Undoubtedly, some practices will succeed in some areas. Sadly, this may be at the expense of other practices and their patients. Yet another postcode lottery.
It is worrying that he is unable to be honest with the electorate that he is out of ideas to deliver on his over-ambitious promises. Is he really unable to "change consumer expectations of healthcare provision" or is he just unwilling to face the electoral consequences of promises he never expected to have to deliver on?

Physician Associates: hold the bunting!

Letter to the editor of BJGP in response to Drennan et al's paper "Physician associates and GPs in primary care: a comparison."

Dear Sir,

It is premature to hang out the bunting, declare the primary care workforce crisis over and allow GPs to retire to the golf course en masse.

Parle and Ennis are to be congratulated that the effectiveness to which they trained Physician Associates (PAs) for two years has been demonstrated by Drennan et al. It does make one wonder why we would bother spending 10 years training every new GP!

The stated headline "consultations carried out by physician associates, compared with GPs seeing comparable patients are associated with similar processes and outcomes at lower consultation costs" is inaccurate. The results state the average PA consultation was 5.8 minutes longer than the GP equivalent. The cost per consultation was £6.22 less for the PA. This equates to 2 fewer patients per hour, fully negating the £24 saved in direct consultation costs.

This cost also does not include additional issues including prescribing time for non prescribing PAs, an activity which, more often than not, will have to be carried out by a GP. Another significant cost that has not been accounted for includes the medicolegal risk (and associated financial cost) supervising GPs will have to bear.

Furthermore, it is unfair and unreasonable to expect PAs to work beyond their competencies and comfort zones to replace people they were never intended to replace.

The closing statement of the article "PAs potentially offer an acceptable, appropriate, and efficient addition to the general practice workforce" is therefore misleading on all counts. If you want someone to do a doctors job appropriately, efficiently, and acceptably then you should employ a doctor. We desperately need more GPs, but if demand exceeds even a generous new supply of doctors, then it is demand and whoever is whipping it up that must be addressed.

By all means invest in primary care provision but PAs, based on this evidence, represent a false economy.

Yours faithfully,

+John Cosgrove
+Roger Scott
+Ben Davies

Notes from RCGP Council meeting 27 February 2015

Put Patients First

I congratulated College officers and staff on the success of the Put Patients First campaign in attracting new funding to General Practice [albeit non-recurring]. As College works more collaboratively with government to attempt to address the workforce crisis, I expressed relief that an intention to highlight the challenges currently faced by General Practice also remains part of College strategy.

Practice-based pharmacists

I welcomed the announcement that the provision of practice-based pharmacists is to be supported. I observed that, anecdotally, many GP colleagues have found the assistance of a pharmacist invaluable in medicines reconciliation, repeat prescription monitoring, medication reviews and audit.

Health inequalities

I applauded a comprehensive paper on health inequalities and the role of General Practice in reducing them. I was particularly pleased about the way in which members and faculties were consulted and their views (including mine) incorporated.

I noted that the NHS GP contract has until now helped to minimise inequalities in healthcare provision, requiring us to meet the reasonable needs of our patients rather than all their wants. This is now under threat thanks to the culture of consumerism, intolerance of risk and complaints and awareness campaigns.

With apologies for the delay in publishing this report.

Reducing health inequalities: does general practice have any role?

We need clearly to differentiate healthcare inequality from health inequality. Much mischief has arisen from the misnomer "National Health Service" as opposed to "National  Healthcare Service" (Iona Heath, 2007). Attempting to use the resources of the NHS to create health has denied resources to those whose health is most unequal, the sick.

Healthcare professionals must be clear to government that health and health outcomes are influenced more by every government department other than the Department of Health, and that they cannot abdicate their responsibility for health by medicalising the population.

There are, for example, questions of overtreatment, such as whether the benefit of statins (which should be but probably are not prescribed preferentially to the less affluent) outweighs the opportunity cost of treating the sick and whether such strategies inadvertently absolve other sections of society of their responsibilities to improve living standards.

The importance of universal access to healthcare gets a mention in the WHO report on the Social Determinants of Health. Universal access in the UK through the NHS is now under threat. GPs used to be relatively free to meet the reasonable healthcare needs of their patients. This freedom (and therefore healthcare equality) is now endangered by these emerging factors amongst others:

• consumerism
• intolerance of risk
• intolerance of complaints
• "awareness" campaigns

set against:

• limited total NHS budget for an ageing population with more complex healthcare needs
• relative underfunding of general practice
• an increasing expectation for the NHS in general and GPs in particular to address social needs

Yes, timely access for all is important, but we must ensure that measures to improve access actually do benefit those most in need rather than increase competition for access for those in greatest need and most able to benefit from healthcare.

Closely allied to health inequality is inequality in health literacy. This has a very direct impact on how effectively health services are accessed. GPs have more than enough to do to be able to provide health literacy education, but as a profession - and even as a network - GPs represent an enormous resource of expertise for schools and communities looking to improve health literacy.

Having worked in areas of greatly differing healthcare needs, my perception is that funding policies (which determine for which conditions treatment should be funded by the NHS) are more stringent and more strictly enforced in areas of lesser healthcare need. We must, therefore, take care not simply to fund areas of greater healthcare need equitably, but ensure that every pound is spent just as effectively, regardless of postcode.

So what could general practice do to reduce health inequalities?

1. Maintain pressure on government and society to retain responsibility for health
2. Question medical treatment of the normally well
3. Evaluate equality of measures to change access to GPs
4. Facilitate debate on acceptable levels of risk rather than "safety"
5. Provide better support for colleagues who receive complaints (more assertive if appropriate)
6. Champion the healthcare needs of the disadvantaged and ignore "awareness" campaigns relating to those with lesser need
7. Continue campaigning for better resourcing of general practice
8. Resist calls for non-healthcare interventions to be delivered using healthcare resources
9. Support health literacy across all ages
10. Champion equity of commissioning decisions especially where health inequalities exist

@tobysteel1 @timsenior @DrJohnCosgrove @PH_darlington @healthwatchDton Max health gain/£ by GP spend in poorest areas http://t.co/Rz8GJSxg3e

— Tim Lawes (@DrTimLawes) February 15, 2015

@pash22 @timsenior Thanks Ash. Good point, esp as harder to recruit in deprived areas

— John Cosgrove (@DrJohnCosgrove) February 15, 2015