Saturday 19 November 2016

Notes from RCGP Council meeting 19 November 2016

New Chair

New Chair +Helen Stokes-Lampard set out her priorities, including encouraging delivery of GP Forward View, improving College's offer to members, and reviewing the MRCGP exam. Her vision for modernisation of College seems to include more transparency: her first action was to allow tweets from Council to be live (i.e. removing the one hour delay).

GP Forward View

There was extensive debate about GP Forward View, in which Council considered concerns about its implementation. College will shortly publish an assessment report on implementation.

Membership by Assessment of Performance

Council approved a proposal to allow prospective members more time (five years, to tie in with revalidation cycle) to collect evidence to support application for Membership by Assessment of Performance (MAP).

I suggested that candidates be allowed to collect evidence across each criterion over the whole five years to allow more flexibility. This was not accepted; each criterion will have to be achieved over one year.

I also suggested that we consider allowing nomination to fellowship of non-members. Many leading GPs are not members, either because they qualified before MRCGP was a requirement or because their membership has lapsed, but would otherwise be ideal candidates for fellowship and therefore potential new members. President +Terry Kemple promised this would be explored during the review he plans to lead.

Friday 11 November 2016

From the medical student in the corner: how my GP placement changed my practice...

Students are, quite rightly, encouraged to go with that natural urge to empathise with our patients. However, little is taught about protecting your emotional self. For example I saw a 50 year old lady suffering greatly with anxiety. I felt upset, and thought about her many times in the evening and over the weekends. Feeling this way with multiple patients was exhausting, so out of necessity I reluctantly started learning to distance my own emotions.

From speaking to colleagues and watching consultations I learnt that treating the patient in the best possible way doesn’t require me to wholly and completely emotionally invest in each case I see. On reflection, I realise that objectivity fosters logic and rationale and therefore probably better patient care. Equally, I also recognise that I’m human and it will still get to me sometimes.

The lady mentioned above did not want medication or a sick note. She needed somewhere to unburden, and someone to monitor her mental health. Being inexperienced, I felt uneasy not actively doing anything for her. I am learning that where a competent patient refuses any action (and it’s clinically sound to acquiesce) active listening can be therapeutic. Writing her name on a prescription pad to make myself feel better has ethical implications; not only in and of itself, but also practical ones in exposing the patient to unnecessary risks and side effects.

Conversely, problems also arise when the patient is expecting a particular course of action to be taken. Take, for example, antibiotics. I witnessed and tried replicating multiple brilliant explanations about the dangers of resistant bacteria, after which the patient no longer wanted antibiotics. Part of the skill here is eliciting the patient’s agenda early on so that it can be overtly addressed, and the patient leaves feeling safely treated.

Before this GP placement, in my independent consultations I would always avoid addressing management options where I knew the patient’s agenda was not going to match the best treatment option, antibiotics or otherwise. I would leave the GP tutor to address the mismatch of expectations versus reality when they reviewed the patient with me afterwards.

Now I address it myself, albeit with varying degrees of success which there are not sufficient words to explore here.

In summary, I now see the value of doing nothing, addressing the patient’s agenda even when it’s hidden and finally protecting my emotional state: not big headings on the curriculum, but nonetheless changes I have made.

My GP placement this year changed much of my practice. In fact I went from being unsure about medicine as a career, to knowing that I would definitely thrive in community medicine.

Sunday 25 September 2016

Notes from RCGP Council meeting 23 September 2016

Hustings for Vice Chair (External Affairs)

Four candidates are standing for election: myself, Gary Howsam, +Jonathan Leach and Martin Marshall.
This was my pitch:

So why should you vote for me as Vice Chair (External Affairs)?

Over the years, College has been phenomenally successful in raising standards in General Practice such that GPs rightly enjoy unprecedented levels of respect from colleagues, patients and policy makers. Under Maureen’s inspiring leadership, we have won the argument for new investment into General Practice. In the challenging times we now face, we are now all too well aware of the need to ensure that new resources reach beleaguered grassroots GPs.

As such, it has never been more important for College to be outward-looking. As Vice Chair (External Affairs), I will continue to support our dialogue with policy makers. Engaging the support of patients and carers will be vital and I look forward to liaising with the Patients and Carers Partnership Group to this end.

One key relationship for College is that with the BMA, especially in ensuring that GPs benefit to the max from GP Forward View. Naturally, the two organisations have different voices, which has the potential to be confusing for our members. We already have close ties with the BMA, LMCs and GPC, at Faculty, Council, Officer and staff levels and I will seek out new opportunities for even closer liaison.

I was elected to Council with a mandate to improve transparency and to close the gap between what we promise on behalf of GPs and the resources available. I championed our new policy to allow tweeting of Council meetings and sharing of draft papers. As Vice Chair, I will be better placed to advance both of these priorities. Not only will I continue looking for practical ways to improve the transparency of College to our members, but I will also explore ways to improve communication within Council between meetings, to assist you as Council members as you liaise between central College and the members you represent. Drawing from my experience on the Overdiagnosis group and positive reports from other committees, options might include an email discussion channel which Council members can dip in and out of when time and interest permit.

What personal qualities and experience will I bring to the role?

I am completely committed to College, having been active first at Faculty level and latterly in Council ever since I became a GP 12 years ago. I have a variety of experience of General Practice as a trainer, a locum, a salaried GP, a clinical assistant in secondary care, a medical director of a walk-in centre and as a partner of one of the first superpartnerships. I have worked in urban and rural settings and with affluent and deprived populations. As such, I can relate personally to the challenges faced by members working in each of these settings.

You will know that I have long been a keen user of social media. I helped to set up Resilient GP and, more recently, GP Contract Forum. The relationships that formerly isolated GPs can now form with colleagues online has become a strong force. Inspired by the enthusiasm of Helen our next Chair and Maureen and Clare before her, I am keen to continue with attempts to harness this force to engage with and consult our members better than ever before.

Thank you for listening and, in due course, voting for me! If you have any suggestions, do please get in touch. As your Vice Chair, I will always be open to new ideas so as to ensure that College thrives and, in the words of Terry Kemple, General Practice never finds itself in the doldrums again.

Council members will vote for the next Vice Chair (External Affairs) between 26 September and 14 October. Please contact your Council or Faculty rep asap and ask them to give me their first preference vote!

Perinatal Mental Health position statement

I applauded a paper by Judy Shakespeare et al. on perinatal mental health, excellent in part because of the perinatal mental health toolkit available on the RCGP website, which looks like a fantastic resource for GPs and their patients. I was also pleased to see its call for commissioners to improve perinatal mental health services.

I called for the wording of one of the "key messages for GPs" to be adjusted. It currently reads:
"Many women are reluctant to disclose perinatal mental illness. However, if a woman does disclose problems this is a 'red flag'; it is possible that she is unwell, and the GP should explore in detail before reassuring or normalising her feelings."
Given that sifting normality from illness is the essence of general practice, I felt that this wording was not helpful. Furthermore, the evidence cited in the paper suggested that there are actually more false positive diagnoses than missed diagnoses (for adults with depression in primary care).

The wording of this "key message" will be adjusted accordingly.

Direct election of Chair of RCGP

Dom Patterson and +Margaret Mccartney proposed that the Chair of RCGP should be elected directly by the membership. Council were not happy to accept this principle in advance of a detailed proposal but Chair-elect Helen Stokes-Lampard promised a working group to explore ways to improve engagement of Council with members.

Role of homeopathy

Having rejected homeopathy in November 2015, Council rejected a rebuttal paper prepared by the Faculty of Homeopathy. Council's view was so clear that a vote was called very swiftly. Had there been more of a debate, I would have highlighted that the view of the vast majority of our 50,000 members regarding homeopathy was very clear. In contrast, the Faculty of Homeopathy include only 101 RCGP members. Furthermore, the grade of evidence cited in their rebuttal paper was much weaker than that presented by the RCGP Overdiagnosis group in November.

General Practice at Scale

I was concerned that the recommendations for larger GP organisations contained within this paper prepared jointly with the +Nuffield Trust did not include good evidence of benefit, nor were uniquely applicable to larger organisations.

For example, e-consultation software and telephony were cited as examples of demand management. I am not aware of any robust evidence that such systems reduce demand. They are also not unique to large organisations: only last week, I was working at a practice with a patient population of 6,000 which operated a "total telephone triage" system.

Saturday 18 June 2016

Notes from RCGP Council meeting 18 June 2016

Live Tweeting

For the first time, a stream of tweets was sent from this Council meeting by staff observers using the hashtag #RCGPCouncil. This builds on the #OpenRCGP transparency policy which I and others brought to Council and which was approved in February.

GP Forward View

There was discussion of this NHS England document, described as a statement of ambition, developed in partnership with RCGP and HEE, which sets out investment and support for General Practice growing over the next 5 years. RCGP is establishing a network of 22 GP Forward View Ambassadors to monitor Sustainability and Tranformation Plans locally and ensure delivery of GP Forward View.

I urged RCGP to work in collaboration with GPC/BMA in subsequent negotiations. I suggested that RCGP has a role in supporting practices in securing the promised funding.

When I asked where the funding had come from to support GP Forward View Ambassadors, the answer was from renegotiation of the mortgage on RCGP headquarters.

Collaborative Care and Support Planning

Council endorsed a vision of person-centred care planning at the heart of the management of long-term conditions in General Practice.

I stressed the importance of considering how to free GP time in order to be able to undertake care planning and suggested that support be developed within GP IT systems to make this process as time efficient as possible.

Fuel Poverty Referral Pilot

I reiterated my concerns that a GP referral will become de facto an essential criterion before vulnerable citizens in fuel poverty receive the help they need and that other agencies such as social services will then abdicate their responsibility to identify the vulnerable.

I predicted that there will be opportunity costs when those that could have been identified by others come specifically to a GP for referral to address their social needs, diverting GP time from those with healthcare needs.

I requested that the pilot study monitor how many patients specifically request referral from their GP regarding fuel poverty, to try to give some idea as to the increased demand this process places upon GPs.

Thursday 17 March 2016

NHS England test standards INCREASE risk

Yesterday, NHS England published a document setting out standards for the communication of patient diagnostic tests on discharge from hospital which dismayed GPs, who interpreted it as suggesting that GPs could be held responsible for acting on the results of tests ordered by hospital clinicians. +Pulse Today report that the most controversial element, Standard 5, has since been revised. Here is my response:

I am most relieved to see this clarification of Standard 5. Maureen Baker, NHS England and others are to be congratulated for their work to achieve such a rapid revision.

I remain concerned about elements of this document, however.

The second guiding principle ("Every test result received by a GP practice for a patient should be reviewed and where necessary acted on by a responsible clinician even if this clinician did not order the test.") sounds like a sensible safety net. However, how is the GP to know whether or not the result of a test they did not order has been acted on by the requestor? Equally, how can the requestor of any test know that the GP is competent to act on the results of a test that they might not be familiar with?

Similarly, Standard 7 ("Appropriate systems and safety net arrangements should be in place in primary and secondary care to ensure any follow-up diagnostic tests required after discharge are performed and the results are appropriately fed-back to patients.") opens up potentially unsafe ambiguity about the responsibility of post-discharge tests, especially if discharge summaries are delayed. I am sure every GP has received a discharge summary advising blood tests to be carried out BEFORE the discharge summary actually reaches the GP!

GPs should not be the default safety net for everything. Requestors of tests should retain responsibility for arranging them and actioning the results and should ensure that they maintain reasonable safety nets.

GPs are not community house officers. If a hospital doctor has made the decision that a test, prescription or referral is required, they should arrange that. If, on the other hand, they believe that the opinion of a GP (who is well placed to know what can be arranged in the community) would be helpful, they should advise the patient to consult their GP on a routine basis after the discharge summary or clinic letter has been received by the GP.

I fear this guidance actually INCREASES the risk that post-discharge tests will not be arranged or acted upon by introducing ambiguity in responsibility. BMA guidance in this area is much clearer and should stand.

Friday 26 February 2016

Notes from RCGP Council meeting 26 Feb 2016

I am delighted to say that the proposal has been approved for all Council documents to be made available to all members in advance of discussion and for Council meetings to be live tweeted. This builds on a proposal I submitted with Jonathan Leach and Kirsty Baldwin last year. My thanks to the short life working group that finalised this proposal.
Appraisal and revalidation
In response to a paper proposing amendments to the process of appraisal and revalidation, I made the following intervention:
"I welcome this clarification, as local variation in implementation of appraisal and revalidation has caused some consternation and confusion.
"However, I wonder if we can go a lot further in reducing the workload burden. Whilst any individual idea might have merit, I cannot support any proposal for additional documentation [such as the proposal in this paper for written reflection on patient feedback every single year].
"Revalidation has been operating for 3 years and appraisal in roughly its current form for 12 years. Many GPs now feel that the general burden of workload has become intolerable. The Special LMC Conference on 30 January 2016 recognised the contribution appraisal makes to that workload and called for appraisal intervals to be lengthened to 2 years and for the process to be simplified and restored to a formative process. This is therefore a good time to review the process.
"I canvassed views on the Resilient GP Facebook group which has 3,700 members. In the interests of full disclosure, perhaps I should mention that I helped to found the group but left the Resilient GP partnership a year ago.
"Just asking the question clearly touched a nerve, as a lively debate ensued.
"One member suggested that preparing for appraisal makes him feel “irritated, demeaned, devalued and mentally shut down”. 86 out of 126 respondents agreed with him.
"I implied that revalidation should raise standards in General Practice. Numerous respondents expressed grave doubt that there was any evidence that revalidation had achieved that objective. We are calling on CQC to test its inspection regime against meaningful outcome measures; should we not insist on the same for revalidation?
"There was even the suggestion that raising standards had never been the purpose of revalidation. Given that the charitable object of College is “to encourage, foster and maintain the highest possible standards in general medical practice”, should we remain engaged in a process which does not?
"Let us withdraw our support for the collection of evidence and completion of numerous boxes, be they tick boxes or even more time-consuming, and promote a formative process in which documentation and writing is kept to a bare minimum."
Council nevetheless approved the paper without amendment.

Thursday 4 February 2016

Managing conflicts of interest of regulators on RCGP Faculty board

Prof Steve Field, Midland Faculty board member and Chief Inspector of General Practice "said that what he had found made him ‘ashamed’ of his own profession" and "that we’ve failed as a profession" - Daily Mail, 12 December 2015.

This evening, Bill Strange and I presented the following motion to RCGP Midland Faculty board which we had written with Mary McCarthy:

  1. “Senior employees of organisations whose main purpose is inspection and regulation to which a significant number of members of Midland Faculty are subject should be excluded from discussions and votes of the board of Midland Faculty RCGP, unless specifically requested by a majority of board members.”
  2. “Any board member who publicly presents a position that is perceived by a significant proportion of our members as being antagonistic and inflammatory, such that the role of the board might be questioned by our members, should be removed from the board.”
The motion was not carried. 11 voted against, 6 for and 1 abstained in a secret ballot.
Prof Field had submitted his apologies for the meeting.

We had set out our arguments in this accompanying paper.

Points of discussion included:
  • Unanimous disapproval of Prof Field's reported comments
  • Unanimous disapproval of CQC's approach to inspection in general practice, causing more disruption than benefit for the majority of practices as a result of a failure to target failing practices
  • Unanimous disapproval of CQC's "Intelligent Monitoring" data publication
  • Unanimous condemnation of CQC's failure to celebrate success as it had promised
Arguments against the motion included:
  • Might Prof Field behaviour have breached the RCGP members' code of conduct, which would be a matter for RCGP Hon. Sec. rather than a Faculty. (Any complaint must be made within 3 months of matter in question)
  • Adopting this as policy would require approval by RCGP Council, a process that could be exceptionally lengthy
  • Concern that reacting to a specific case was not the best way to make policy
  • Concern that point 1 could include members whose work includes regulation
  • Concern that point 2 amounted to censorship
If anyone else present at the meeting has a different recollection, do please leave details in a comment below.

Wednesday 27 January 2016

Premedication by GPs - complaint to PHSO

By email.
27 January 2016

Dear Dame Mellor,

We, as a group of GPs, would like to bring to your attention our concern over a growing trend of requests for the prescribing by GPs of sedative medication for reasons such as investigative scans, dental treatment and on one recent occasion, for which we believe your office was involved, as pre-operative medication. Due to the potential risks involved sedation requires close monitoring and should therefore be the responsibility of the professional who is carrying out the procedure/investigation and able to ensure that proper precautions are taken (Academy of Medical Royal Colleges 2013, Safe Sedation Practice for Medical Procedures,, over which a remote prescriber such as a GP has no control.

The case in which we believe your office was involved is concerning to us all. We seek clarification of your role in this case and reasoning for the advice that was given to the patient involved.  The case details are as follows:

A patient was due to undergo a cataract operation about which they were extremely anxious and was instructed by the ophthalmologist involved to obtain a prescription for diazepam from the GP, to be taken on the morning of the planned procedure.  The GPs whom the patient requested this from declined to prescribe on safety grounds for reasons stated above. These reasons were explained clearly to the patient. The ophthalmologist was informed both verbally and with a letter.

The patient, dissatisfied at the GPs’ decision, allegedly contacted your office directly and was informed that it was the GPs’ responsibility to prescribe the sedative medication.  So far as we know, your colleagues made no attempt to gather information from the GPs involved and no written confirmation of the advice given by the Ombudsman has ever been received by the GP practice.

In an era of ever-increasing workload in the NHS it is of course important for colleagues to work collaboratively. However, this must be done appropriately, with prior  agreement, and with patient safety at the heart of the process. Taking responsibility for sedation during a procedure, which anyone who prescribes a pre-operative sedative drug accepts, is not part of a general practitioner’s areas of duty or competence.

The guidance from the Academy of Medical Royal Colleges (cited above) emphasises the importance of responsible sedation. We therefore find it most worrying that staff in your office might have given the impression that a GP should be expected to provide such a prescription without any attempt to gather details about the case.

We would like to draw your attention to the “Shared care” chapter of the General Medical Council’s 2013 guidance “Good practice in prescribing and managing medicines and devices” (, particularly paragraphs 35-39:

Prescribing guidance: Shared care
35. Decisions about who should take responsibility for continuing care or treatment after initial diagnosis or assessment should be based on the patient’s best interests, rather than on your convenience or the cost of the medicine and associated monitoring or follow-up.
36. Shared care requires the agreement of all parties, including the patient. Effective communication and continuing liaison between all parties to a shared care agreement are essential.

Prescribing at the recommendation of a professional colleague
37. If you prescribe at the recommendation of another doctor, nurse or other healthcare professional, you must satisfy yourself that the prescription is needed, appropriate for the patient and within the limits of your competence.
38. If you delegate assessment of a patient’s suitability for a medicine, you must be satisfied that the person to whom you delegate has the qualifications, experience, knowledge and skills to make the assessment. You must give them enough information about the patient to carry out the assessment required. You must also make sure that they follow the guidance in paragraphs 21 – 29 on Consent.
39. In both cases, you will be responsible for any prescription you sign.

This guidance would appear to preclude the prescribing of pre-operative or sedating medication for investigations by most General Practitioners, as they will not be familiar with the appropriate dosage for sedation nor in a position to monitor the patient for adverse effects, but as signatory to the prescription would be liable for any effects or adverse consequences of the drug.

We believe these important safety principles should be enshrined in policy at every level to protect patients’ safety and allow health professionals to continue to practice safe medicine. No doctor, whether based in general practice or hospital, should ever be coerced into prescribing any drug they do not feel they have sufficient knowledge of or competence to prescribe. We trust we can rely on you and your office to support these important safety principles.

We have put this letter in the public domain and would be happy to do the same for your reply.

Yours sincerely,

Two of the GPs of the patient in question (anonymised in the interests of patient confidentiality),
+John Cosgrove, GP, Birmingham,
John Hughes , GP, Manchester,
+Fran Ferner, GP, Cardiff,
+Emma Nash, GP, Portsmouth,
Tom Caldwell, GP, Worcester,
Hanne Hoff, GP, Farnham.

Reply received 2 February 2016:

Dear Dr Cosgrove
Thank you for your email to Dame Julie Mellor on 27 January 2016. I work in Dame Julie’s Corporate Casework Team and I have been asked to respond on her behalf.
I have read your email and can see that you have anonymised this information in the interests of patient confidentiality. Unfortunately, without the specific details of the case such as the name of the complainant/doctors and/or GP Practice we are unable to respond to the concerns you raise.
I should add that if the doctors involved have any concerns about our decision making they are entitled to ask us to reconsider the case. We can then take a view as to whether our decision was sound. Details of our review process can be found on our website at and this process is open to organisations in our jurisdiction as well as complainants.
I am sorry that we are unable to respond to your concerns at this time but if you would like us to consider the specific case then please ask the doctor(s) concerned to contact me.
Yours sincerely
Nicki SmithExecutive Assistant (Corporate Casework Team)Parliamentary and Health Service Ombudsman

My response 2 February 2016:

Dear Ms Smith,

Thank you for your response. Please note that we were not looking for feedback on this specific case. Could you please confirm Dame Mellor's agreement with the principles we have described?

Yours sincerely,
John Cosgrove.

Latest reply received 15 February 2016:

Dear Dr Cosgrove

Thank you for your email in which you ask us to confirm that Dame Julie agrees with the safety principles you relay in your first email. Whilst we recognise you are seeking an answer to the broad application of the safety principles we are unable to do so because our role is to provide final decisions on individual cases.  As I said in my previous email, we can consider any concerns that the doctors involved may have in our decision making. It remains open to the doctors involved to make a complaint to us about our decision making.

Yours sincerely

Nicki Smith
Executive Assistant
Parliamentary and Health Service Ombudsman

Thursday 21 January 2016

Why schools should not say "Get A Note From Your Doctor"

According to the Mail on Sunday, a growing number of schools are now demanding that parents of children unfit to participate in PE lessons consult GPs for letters.

"Bundesarchiv B 145 Bild-F010151-0007, Salzgitter-Lebenstedt, Volksschule" by Bundesarchiv, B 145 Bild-F010151-0007 / Steiner, Egon / CC-BY-SA 3.0. Licensed under CC BY-SA 3.0 de via Wikimedia Commons.

GPs are contracted to treat those who.are unwell or believe themselves to be unwell. In reality, most people know well that most illnesses are self-limiting and do not require medical treatment. If everyone consulted a GP about every self-limiting illness, we would be swamped. (Clearly, establishing that an illness is self-limiting can only be done confidently with hindsight; until then, judgement and risk-taking is required, whether that be of the patient or parent or of a healthcare professional).

With the growing workload in general practice and finite resources, it is imperative that we move towards less professional healthcare involvement (and/ore acceptance of risk by patients/parents/teachers/employers) in the treatment of self-limiting illnesses.

Writing notes for school is not an activity that GPs are contractually obliged to undertake. As such, they would be entitled to charge parents for such work if no other body is willing to fund it. This has the potential to discriminate against those least able to pay, also likely to be those most likely to be unwell. The blame for such discrimination would consequently lie squarely with those setting this policy, not with GPs.

Of course, it is not all about money. A very real danger here is that this policy will encourage more parents to bring their children to see their GP for self-limiting illnesses or perhaps even non-medical problems. The cost of this will be that the unwell will have to compete with this new group of patients for access to healthcare.

I also question whether I as a GP would be best-placed to make an assessment of whether a child is fit to exercise. If a parent says they are not, I would be inclined to believe them. If this happens frequently and they do not have a chronic medical condition (and would therefore be likely to provide evidence such as repeat prescriptions, obvious disability or hospital appointment letters), I might gently challenge that view. There is no reason why a teacher or school nurse could not do the same.

If a school nurse had concerns about a child's health (or perhaps that they might be missing too much PE), I would be very happy to speak to them as one healthcare professional to another.

If trust between parents and teachers has been lost, it is not the responsibility of GPs.

If anyone thinks general practice might be able to help with a particular problem, they should reach agreement with GPC before issuing advice to a population. This was one of the recommendations (3.3) contained within the Further Blueprint for Primary Care I co-wrote with Dr Hussein Gandhi (+Dr Gandalf ) in June 2015.

This is the full version of a response of mine quoted in an article in +Pulse Today.