Saturday 24 November 2018

Notes from RCGP Council meeting 24 November 2018


Council voted to support a People's Vote on Brexit. I spoke in favour of this motion:

I had seconded a motion passed by Council in September 2018 setting out the risks to quality care in general practice. Accepting the two statements in today's motion proposed by Margaret McCartney and John Chisholm is therefore the only logical position for RCGP to adopt. Will adopting this position make a difference? It is certainly highly unlikely to have zero impact and, in collaboration with other bodies, may well have a very constructive impact.

Other matters

Within an otherwise full agenda, Council also considered a future vision for general practice (the product of over 2,000 submissions from members) and a policy statement on out of hours and urgent care.

Chair of Trustee Board

Nigel Mathers (previous Hon. Secretary) introduced himself to Council as the new Chair of Trustee Board. This is an important position as trustees have a big impact on members' experience of RCGP. I look forward to his leadership as "millenials" become a larger component of our membership.

Friday 21 September 2018

Notes from RCGP Council meeting 21 September 2018

I spoke to three agenda items.

Trustee board

As I frequently do, I raised two questions relating to confidential trustee matters.


In response to a paper from RCGP Clinical Champion for Sepsis, Simon Stockley, I made the following speech:
My first exposure to the sepsis awareness campaign was when I was lambasted on Twitter by one of the leading lights of that campaign, a medical colleague, for having the temerity to question the utility of the alarming prompts that appear on SystmOne whenever one so much as types the word "fever". I am pleased, therefore, that College have identified sepsis as a clinical priority, and I am grateful to Simon Stockley for his more nuanced approach.
Other than turning off the computer prompts, my response to the sepsis campaign has been to attempt to measure and document physiological variables more often, and I'm sure many colleagues do also whenever their clinical judgement leads them to suspect a patient with infection is severely unwell. Indeed, I accept that this aids communication of urgency to ambulance services and hospital colleagues.
It has been argued that documenting physiology when one does not suspect severe illness can later aid one's defence if severe illness subsequently develops. However, given the vast number of presentations of infection in general practice, to do so every time would have major resource implications.
I strongly doubt that, contrary to intentions stated in the clinical spotlight survey, 62% of adults presenting to their GP with coryza or paronychia, for example, have their respiratory rate quantified and documented. To do so reliably would require a systematic approach, such as for all patients to be assessed by a health care assistant before seeing the GP - an approach that actually worked well in the walk-in centre I used to direct, but requires a team of HCAs and twice as many consultation rooms.
Simon acknowledges the challenges of paediatric pulse oximetry. Are we really saying that any practice without adequate pulse oximetry equipment is unsuitable for assessing babies?
Rather than mandating sepsis training and the calculation of a sepsis score for every patient a GP sees, this is an opportunity for College to support its members by commending their unique skill in distinguishing between patients with unpleasant self-limiting illness and those at risk of septic shock and many other life-threatening conditions. Let us highlight the advantages of documenting physiology but also celebrate GPs' expert clinical judgement, born of years of training and experience. Whilst recognising that nothing short of a crystal ball will infallibly identify the patient that will become severely ill, we should state clearly that a GPs' clinical judgement alone is adequate.
We should develop a position statement on sepsis. It should aim to support the assessment of the acutely unwell but also protect GPs' clinical judgement from unjustified criticism.
 Council decided that RCGP should not develop a position statement on sepsis.


I seconded a motion calling on RCGP to warn of the health consequences of Brexit.
The country voted for Brexit partly on the basis that, according to the now infamous bus, the NHS would be better off to the tune of £350 million per week. The NHS' 70th birthday present was said to be funded from the Brexit dividend; perhaps it is no coincidence that this apparent largesse was actually less than the historic average annual uplift in NHS funding.
It is now becoming clear that Brexit poses challenges to our patients that were either not apparent at the time of the referendum or, if the UK crashes out of the EU with no deal, will not be addressed.
Charged as College is with maintaining the highest possible standards in general medical practice, it is our duty to call attention to these risks for the benefit of both sides of the Brexit debate: Remainers may use this new information to support calls for a fresh referendum; Brexiteers can push for other solutions to be found to these challenges. As such, this motion represents a constructive contribution to the wider debate and does not compromise College's political neutrality.
The BMA and other medical bodies have already set out concerns in relation to Brexit. Our charitable objectives oblige us now to do likewise, for the benefit of general medical practice and our patients. I am grateful to colleagues in the Midlands for drawing this motion together in a way that we can support and I encourage Council to do so.

Tuesday 26 June 2018

Submission to GP Partnership Model Review

Dr Nigel Watson has been appointed to lead an independent review of the GP partnership model. Here is my submission to that review.

There is a danger of conflating the advantages of the GP partnership model with the employment status of GP principals (usually self-employed).

The advantages of GP-owned independently contracted practices include:

  • senior clinicians - GPs - still in clinical practice have responsibility for a population and make decisions for the practice.
  • an unparalleled sense of ownership by GPs and willingness to go the extra mile for practice and patients.
  • remuneration is linked to the performance of the practice.
The potential disadvantages of GP partnership include:
  • unlimited liability (when the viability of a practice is often beyond the control of GPs)
  • lack of clarity/predictability of pay to individual GPs
  • no access to PAYE, childcare vouchers and other benefits of employment.
Most of the advantages of the GP partnership model to the NHS relate to GPs owning their practices. Why must we insist that they are also self-employed?

The ideal model of GP contracting would allow practices to:
  • limit their liability and
  • hold a GMS contract and
  • retain access to the NHS pension scheme for their staff and
  • let them decide for themselves how to contract all of their staff, including GP principals.
For example, a practice could operate as a limited company, include their GP principals as directors, pay all staff (including GP principals) a basic salary. Staff could be awarded or allowed to buy shares in the practice, on the basis of which they might receive dividends and/or voting rights. Whilst current GP principals might hold most of these shares, sharing them with currently salaried GPs if not other staff also would be a way of re-engaging them and giving them a greater sense of ownership.

Notes from RCGP Council meeting 23 June 2018

Highlights from this meeting included the following.

A new vision for General Practice

A draft paper on the future role of GPs.

Person Centred Care

This approach, which RCGP has been developing since 2012, revolves around the maintenance of a written care plan for each patient as part of a collaborative partnership between patient and health professional, not least to help patients identify resources within themselves and their community to manage their wellbeing.

It was suggested that the language used was unhelpful, implying disempowerment of both doctors, who must provide whatever patients need, and patients as passive recipients of care, which is presumably the opposite of that intended.

Challenges were also made to the recommendation for social prescribing by doctors. [There is insufficient evidence that it is successful or value for money.] It was suggested that doctors should instead only do that which a medical licence is required for.

Urgent and Out-of-Hours Care

Tentative suggestions that all GPs should regularly undertake some out of hours work were not welcomed.

Sponsorship consultation

A consultation is underway to reframe RCGP's policy on accepting sponsorship. Please share your views with your Faculty board as a matter if urgency.

I thanked the Chair of trustees for taking on feedback from myself and others in designing this consultation but observed that some respondents are still finding the survey confusing. Some Faculties are asking board members to respond individually, rather than provide a single consensus answer as would apparently be preferred. I asked how we would ensure that the votes of Faculties are weighted according to their size rather than the number of responses.

I noted that the Hon. Secretaries must be grateful to have had help in administering this consultation but suggested that the Chair of trustees, inscrutable as he no doubt is, might have an interest in preserving the status quo and therefore in future it might be preferable to allow the Hon. Secretaries to coordinate consultations on behalf of the trustee board, as they do for other RCGP consultations.

Saturday 10 March 2018

Why are doctors being convicted?

Paediatrician Dr Hadiza Bawa-Garba and surgeon Mr David Sellu were both convicted of gross negligence manslaughter in the courts of Mr Justice Nicol in 2015. Mr Sellu's conviction was quashed on appeal. Following the GMC's decision to remove Dr Bawa-Garba from the medical register, there has been widespread condemnation of her original conviction by the medical community.

By Blogtrepreneur (Legal Gavel) [CC BY 2.0], via Wikimedia Commons

What are the key components of the mistreatment of these well-meaning doctors?

1) Sick people sometimes die before doctors can save them
2) Risk intolerance
3) Culture of blaming individuals fuelled by courts and GMC
4) Under-resourcing

These cases tragically highlight the problem with the popular view that no risk is acceptable, medicine can treat everything and if anyone dies after seeing a doctor it is the doctor's fault, usually for not responding quickly enough.

The logical response to this argument is indeed to assess people more thoroughly and treat them more quickly. Most doctors are well aware that all tests and treatments carry risk and cost money and time that taxpayers are unwilling to provide the NHS with.

The reality is that, unpredictably, people become very sick, especially if they have other medical problems and, despite the best efforts of doctors and nurses with the dwindling resources available to them, sometimes, tragically, they die.

The instinct to apportion blame is an entirely understandable component of a grief reaction but is a poor basis for policymaking.

Indeed, blaming individuals discourages candid reflection and identifying the numerous failings across a system usually to be found when errors do occur.

Unfortunately, instead of looking at the all important bigger picture, our courts, the GMC and politicians have all conspired to fuel this blame culture and make patients less safe. The courts rely on evidence not of a doctor's peers at the short-staffed, cash-strapped coalface but disease experts who expect perfection and more. In the Bawa-Garba case, the GMC too yielded to the rule of the mob by rejecting the nuanced view of the doctors of its Medical Practitioner Tribunal Service and instead relied solely upon the arguably flawed judgement of the court. And politicians routinely promise more, better and faster treatment without finding the much-needed money.

Our society has killed the NHS. It must now decide what will rise out of the ashes.

Saturday 24 February 2018

Notes from RCGP Council meeting 23 February 2018

Implications of the conviction of Dr Bawa-Garba

There was extensive discussion about the implications of the conviction of gross negligence manslaughter and subsequent removal from the medical register of paediatrician Dr Bawa-Garba. The mood of Council seemed to be that substantial change was required to ensure this never happened to another doctor again.

I made the following speech:

Many of the players in this case have at best overstated their opinions. The MPS’ statement fails to reassure about the use of written reflections either in this or future cases. It is a matter of record that a form from Dr Bawa-Garba’s ePortfolio was submitted to the court and she faced questioning in relation to it. Furthermore, her reflections were considered by the preceding inquest.
What is concerning is not whether or not evidence of her ePortfolio was used to convict her but that the court did not consider her reflections as mitigation, unlike the Medical Practitioner Tribunal Service, and that honest and meaningful reflections by doctors might in future be demanded by courts and used against them.
In my view, increasing the jeopardy of not being candid was a misstep. What is now urgently needed is to reduce the jeopardy of acknowledging mistakes and missed opportunities so that we can all work together to make our patients safer, just as takes place in the aviation industry.
We must press for legal privilege for reflections by individual doctors on serious untoward incidents. Until then, we should discourage our members and trainees from recording detailed reflections.

In the light of the opinion of the Professional Standards Agency, the GMC have at best been misguided and at worst disingenuous in stating that they had no alternative but to appeal the sensible decision of the MPTS. That they have thus far always won appeals is no justification, as it is now abundantly clear that the courts are unable to distinguish between individual and system failings.
It seems to me that a big failing for courts is the way in which they use expert witnesses, confusing a medical witness who may be expert in a particular medical condition for a peer of the beleaguered doctor on trial.
I have some personal experience of this. A family member found themselves being sued alongside a GP. One of the pieces of evidence used against them was the opinion of an expert witness who admitted that she had not once treated the condition under consideration!
Our work with other organisations should include how we might support courts in receiving the best opinion regarding standards of medical practice. Perhaps College should accredit a cadre of expert generalist witnesses.

College Sponsorship Policy

College will be consulting on a new policy for sponsorship. In June 2018, Council had asked Trustee Board to prepare options for consultation for its approval. I reiterated my suggestion from June that this include principles which potential sponsors must meet, including that if a sponsor seeks to change the clinical practice of College members, that practice must be consistent with College policy. I agreed to submit a set of principles to the Chair of Trustees for consideration of inclusion in the consultation.

College membership recruitment and retention trends

At least partly in response to a previous request from myself, Trustee Board presented membership attrition statistics, some of which I shall shortly add here. These demonstrated that attrition is greatest during the first few years of membership. This stimulated from other speakers suggestions on what more we might do to retain these members. I welcomed these statistics and asked that they be presented to Council regularly. It was agreed that they would be published annually.

E-Consultation and online General Practice

Having been amended in line with feedback from Council, this paper setting out the potential pitfalls of e-consulting was approved. I welcomed the inclusion of the concept of opportunity cost but asked for this, in my view the biggest risk, to be made more prominent. "If GP time is finite, what will we have to stop doing in order to undertake this new work?"