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”.


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 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.