Wednesday 25 November 2020


 So far as I know, each of my concepta* have resulted in a live term baby. I never dared to hope for such good fortune, nor do I take it for granted.

Now that pregnancy can be diagnosed within just 2 weeks of conception (aka 4 weeks gestation, counting from the first day of the preceding period), we know that at least 1 in 4 pregnancies result in miscarriage, usually during the first 12 weeks. Understanding that early miscarriage is so common usually prompts secrecy until the 12 week scan.

Miscarriage must be so difficult for couples. As a GP, I am frequently taken aback by the matter of fact response of patients who have experienced miscarriage.

However, the Duchess of Sussex is not the only one to experience 'almost unbearable grief' following a miscarriage.

Many women have been brave enough publicly to share similar feelings. But where are the voices of those who find different ways of coping? Where are the voices of the men for whom the reproductive implications of miscarriage are usually as significant as for their female partners?
(*no wonder the language is clumsy)

As a society, we definitely need to remove the stigma of miscarriage, if any existed. Crucially, we also need to lift the secrecy that surrounds early pregnancy and miscarriage, and listen to the voices of all those affected, not just the loudest.

Friday 18 September 2020

Notes from RCGP Council meeting 18 September 2020

 My apologies for the lack of notes from the previous two meetings, in part because I was addressing confidential matters.

Here are my speaking notes from what is my last RCGP Council meeting.

Returning Officer's report (of Council election)

Please note that I have a personal interest in this item, as my wife stood in this election.
  • It’s disappointing to see such a reduction in turnout, presumably because of the loss of postal voting. No doubt some candidates will be concerned that this disadvantaged them disproportionately. Do we have data on how the demographics of voters compared to previous elections?
  • It seems to me that we have made great progress with our declaration of interests policy, and are identifying useful learning points, not least how to enforce the rules. Would it be helpful in future to make clear to candidates and others how to report concerns?

Health inequalities

There are two kinds of GP: the first frequently identifies social needs as a driver of ill health, signposts their patients accordingly, and does their best with limited resources to provide medical care to their patient population on the basis of need; the second sees these same needs and believes they have a personal responsibility to address them. Both are seeking the best for their patients.

No GP can be unaware of the link between social need and ill health: even those with the most privileged patient populations will be confronted with this reality by every single consultation. This paper summarises the problem well.

I believe our profession is divided roughly into half on this issue. The dialogue between the two sides can at times be robust, with accusations and implications of ignorance, naivety and lack of compassion. I have been elected to Council twice on a platform of promising to oppose any such mission creep in the GP role. One might think that calls for such an expansion in our remit arise from a profession with spare capacity. On the contrary, however, in the six years that I have been on Council, there has been universal acknowledgement of a shortage of GPs.

One of our more eloquent and distinguished members once said “a GP should do what only a GP can do”. In addition to our obligation to meet the reasonable medical needs of our patients, I believe GPs have a moral duty as a profession to speak out about health inequality and social injustice. I do not believe it is appropriate for us to further medicalise social inequality, thus potentially making ourselves less available to those most needful of medical care and widening the inverse care law yet more.

Projects such as Deep End have been successful in part because they have attracted funding from outside the NHS. This is welcome, but we need to ensure that other resources - not least the availability of GPs - are not taken away from meeting the medical needs of their patients.

That social prescribing and other interventions are effective at reducing health inequality should come as no surprise to any GP or politician. The tests for us as GPs should instead be:

  1. That such interventions have no medical opportunity cost for our entire patient population (rather, they should free up clinical GP time), and

  2. That we are not exacerbating social injustice unwittingly by colluding with society to look after only for those with a doctor’s note.

At first sight, the problem looks simple to any GP. In reality, this is ethically highly complex: health inequality goes to the heart of society and we have a duty as a profession to engage society in the solution.

In terms of next steps, I would suggest that we please seek the input of our ethics committee.