Tuesday 29 September 2015

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.


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.


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.


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


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.

Friday 18 September 2015

Notes from RCGP Council Meeting 18 September 2015


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.