Monday, 23 September 2019

Notes from RCGP Council meeting 21 September 2019

This is what I said at the RCGP Council meeting on 21 September 2019.

Transparency

(in response to the report of the Chief Operating Officer, Valerie Vaughan-Dick)

Valerie, thank you for all your work and that of our staff in delivering what members, Council and Trustees ask. It is greatly appreciated.

I’d like to refer to digital transformation - your paragraph 11.

I’m aware that there has been much challenge in relation to IT and, in spite of the successful transformation earlier this year, in relation to our website.

Over three years ago, in February 2016, Council approved a motion from the SLWG on balancing openness and transparency with information security, which included the recommendation that:
“all Council agenda, minutes and reports will in future be made available to all College members ... Council documents will be initially uploaded to a dedicated ftp server, but the aspiration is that eventually they will be available to view in the Members Area of the College website, once the technical challenges have been overcome.”
BMJ and other journals have had this functionality now for some time. If a member or subscriber clicks on the link to an article, they are able to read it; if anyone else clicks on it, they see instead a page inviting them to log in.

My understanding is that the latest platform on which our website is based allows this functionality. (If not, I would be interested in knowing why not?) Could you please give us some idea when this will be implemented?

In response, I was warned that there are other priorities for IT which might take precedence, but that development of RCGP's website will continue in spite of any staff vacancies.

NEWS2

(in response to a proposed position statement supporting increase use of the NEWS2 score in primary care)
I'm grateful to the authors for revising this paper and for acknowledging the paucity of evidence for the utility of early warning scores in primary care. On the face of it, their recommendations seem relatively uncontroversial and to represent the consensus.

I am particularly heartened to see the scope expand to "the deteriorating patient", tacitly acknowledging that suspected sepsis is not the only potential medical emergency.

I am relatively relaxed about the proposal to *experiment* with using NEWS2 in primary care: that is largely a simple training/IT issue, and might serve to heighten clinical concern. However, can we please be clear that clinical concern should always trump the requirement for a number, lest ambulances be dispatched with *less* urgency if a primary care clinician is *unable* to calculate a NEWS2 score - or whatever other score happens to be flavour of the month or the county?

Council previously were concerned that requiring GPs to document physiological data was not a reasonable standard, and would therefore expose our members to unwarranted medicolegal risk.

I am concerned that there is still an implication in this paper that not documenting physiological data in those subsequently found to be unwell is unacceptable. Just as the hapless Dr Bawa-Garba found when confronted with sepsis experts, the 2015 Sepsis NCEPOD report repeatedly describes failure to document physiological data as "poor practice" ("poor adherence to the recording of vital signs" as if that were already an evidence-based minimum standard in primary care) and this paper sadly reiterates such language (towards the bottom of page 3) without challenge.

I have not heard anyone disagree that we should record physiological data in general practice, and record it more. The key question is *when* and *for whom* we should record it. There might be an argument for recording such data for every patient encounter. But should the necessary additional resources be forthcoming in the absence of good evidence of benefit?

Can we please say explicitly in this paper that, yes,  recording physiological data is to be encouraged and may support clinical judgement and communication, but that not doing so is not and has not been necessarily poor practice?

Depending upon which patient encounters this recommendation is supposed to apply to, any recommendations need to be evidence-based and appropriately resourced.

Of three proposed recommendations, Council approved two.

Screening

(in support of a position statement written by Margaret McCartney, author of The Patient Paradox)

This is a fabulous position statement incorporating and building on the considered views expressed by Council 2 years ago. It is even more important and needed than it was 2 years ago. I want the backing of this statement behind me when I am advising my patients on Monday morning. If approved, College should promote the message loudly that non-evidence-based screening should be discouraged.

I don't want to wait 2 minutes for this position statement to be approved and promoted, let alone risk another 2 year wait. I therefore move that the question be now put.

This was a very unusual intervention on my part, proposing that Council move to a vote without further debate. I was keen for the statement to be approved without further delay and wanted to offer Council the chance to do precisely that. Council were strongly in favour both of moving straight to a vote and then in favour of the statement itself.

Saturday, 22 June 2019

Notes from RCGP Council meeting 22 June 2019

Here are the speeches I planned to deliver during this Council meeting. What I actually said may have been different due to the dynamic nature of debate, but the sense will have been the same.

Transgender patients

This is a really helpful and timely piece of work. Just as I received this paper, a patient of mine asked if I would be prepared to enter into a shared care agreement with a doctor whom I happened to know had just been suspended by the GMC and was currently practising from another country. The paper acknowledges that shared care agreements should be entered into only if “the appropriate levels of resource, competence and expertise are established”. It would be helpful to members if more detail could be given as to how they might recognise such competence and expertise, such as membership of which professional bodies would be sufficient.

I know a great many colleagues will be heartened to see us challenge the suggestion from the GMC that GPs should initiate bridging prescriptions, undertaking additional training if necessary. It is quite right to say that the GMC advice needs review and clarification. I would suggest that we should also call for a review of the processes that led to such unilateral advice.

When I consulted on this topic, a member with a particular interest in this area suggested that we should refer to the wider term “gender incongruous patients”.

Innovation

This is an area that is captivating the imagination of many of our members, not least now that participation in PCNs is so strongly incentivised.

This provides a real opportunity for College to offer leadership and support by encouraging the sharing of best practice. In particular, I wonder if the Collaborative General Practice might approach local faculties for support, which might for example include educational events or even formal liaison, such as we had with STPs.

Digital services (para 3.1 of the paper) are increasingly widespread but not a “central” part of general practice. They are not appropriate to every practice and community, nor are they necessarily the most important facet of general practice. I worry that “central” implies essential.

Council agreed in 2015 that all new policies should be weighed against the five tests of overdiagnosis:
  1. Shared decision making and patient involvement
  2. Which populations it applies to
  3. Evidence base and opportunity costings
  4. Screening
  5. Declarations of interest
Can I suggest that these tests are made explicit in this paper, for the benefit of the Innovation Programme?

As ever with new technology, we need to beware of the inverse care law and be clear which population(s) stand to benefit most from any intervention and which are at risk of opportunity cost.

SLWG on declarations of interest

When I asked Twitter, 73 out of 76 respondents said that our declarations of interest should be publicly available; when I asked a large Facebook group of GPs, every one of 62 respondents said they should be public.

Thank you to the group whom I know have worked hard to make this proposed policy as strong as it is. I’m really pleased to see progress in this area and the proposal that we will be maintaining a register of interests. I must confess, however, that I was disappointed when I first saw this proposal that the register of interests would not be publicly available. By and large, I see that a great burden has been placed on the Hon. Sec. - just as well there are currently two of them! - or the relevant director to check the declarations of interest.

I understand that there are logistical and data protection challenges, but can we please state clearly our preference that all declarations of interest should be publicly available - whether on whopaysthisdoctor.org or elsewhere, and that the review in three years’ time specifically consider how to ensure that this happens?

Assisted dying – process for consultation review 

Partly in response to concerns raised to me by members, I spoke to this confidential item.

Friday, 22 February 2019

Notes from RCGP Council meeting 22 February 2019

My apologies but family health concerns required me to leave today's Council meeting early. A fellow Council member kindly agreed to deliver my response to the Rethinking Medicine initiative:
Thank you for presenting the Rethinking Medicine initiative. I'm not sure I fully understand the objective of this movement. Hopefully that is because it has not been predetermined.
If we are to engage with this process, we must as a College prioritise:
1) equity and safety for our patients, so that the ill who rely on the NHS, and those that need drugs and other healthcare technology who rely on doctors are not disadvantaged;
2) the best interests be of our members, lest they are expected to take on responsibility for things for which they have neither proper resource or influence.
Mention is made of the importance of social interventions. No-one doubts this. The key is how to get the necessary social help to those most in need, regardless of whether they have consulted a doctor, without diverting NHS resources away from the ill.
The top priority areas selected by our members are:
1) supporting GPs with workload
2) restoring the status of general practice
3) the interface between primary, secondary and social care.
The partnership review identified rising workload and shrinking workforce as key issues. We have been worrying about the mismatch between capacity and demand for some considerable time.
Medicine, the NHS and general practice need to be very careful about taking on new responsibilities.
Yes, we need to be payient-centred. Yes we need to stop overusing healthcare technology. But we must also be careful not to medicalise other, non-healthcare interventions.
As Clare Gerada said a couple of meetings ago, until such time as we have more doctors than we know what to do with, doctors should do what only doctors can do.
We may need to Rethink Medicine. We also need to Reassert Medicine.

Saturday, 16 February 2019

My address to #DiscoverGP at Keele University on 16 February 2019

One of the great attractions about General Practice, and rightly so, is the range of opportunities available. This is certainly one of the things that attracted me to General Practice. I like the idea of being responsible for the healthcare of a population, of managing a team, and running a small business. We are very fortunate to be joined by a number of GPs who have rich and interesting careers. I, and they, look forward to telling you all about the opportunities available in General Practice.

One of the attractions of General Practice appears to be the ability to develop special interests. But I am often asked what special interests I have and I always say my special interest is generalism. I decided on General Practice as a career before I left medical school and undertook specialist training during which, yes, I picked up some specialised knowledge, but above all I learnt the skills of generalism, which is sometimes hard to describe but in the context of super-specialisation elsewhere the value of generalism is becoming recognised more and more.

So what do I mean by generalism? This has many facets. One of the most important is the ability to tolerate uncertainty and manage risk. Let me give you a simplified, perhaps slightly exaggerated, example. You go to a specialist with a cough and they will undertake all kinds of tests, maybe a chest X-ray, maybe some blood tests, and the specialist will tell you with certainty what the diagnosis is. “You have an upper respiratory tract infection; we are certain you don’t have pneumonia; you can be reassured.” The only problem with this approach is that it is enormously expensive and doesn’t really help the patient to know with certainty the next day what their diagnosis is. Contrast this with the generalist approach. You come to me with a cough. In a matter of minutes I will ask you a few questions, and - perhaps more for reassurance than anything - examine you, and I will say that you probably don’t have pneumonia, you probably have a viral upper respiratory tract infection, possibly ‘flu, and specific treatments such as antibiotics are unlikely to be helpful. However, if you develop symptoms of pneumonia such as breathlessness, or become concerned about something else, then do come back.

Do you see the difference in approach? Now, I would be maligning the specialists if I pretended they do not use some of these generalist skills, but this is the bread and butter of what we do in General Practice. Disappointingly for our Secretary of State, it’s low-tech, but it’s really cheap, highly skilled, and empowers the patient to diagnose themselves, not only tomorrow, but also the next time they are unwell.

So that is the specialism of generalism. That is what gets me out of bed in the morning. But yes, there are also a range of opportunities in General Practice. Please do come round to each of us in turn to find out about the portfolio that is each of our careers.