Chocolate Brownies

Ingredients

200g vegetable shortening

200g milk chocolate

300g white sugar

100g demerara sugar

5 medium eggs

2.5ml baking powder

100g all-purpose flour

100g cocoa powder

100g chocolate chips

Method

1. Line a 20x30cm porcelain dish with greaseproof paper.
2. Preheat fan oven to 150°C.
3. Melt the vegetable shortening, turn off the heat, add the milk chocolate, mix thoroughly once melted, allow to cool until starts to thicken, stirring occasionally.
4. Whisk sugar, baking powder and eggs to ribbon stage.
5. Fold in flour, chocolate chips, cocoa chips and cooled milk chocolate and vegetable shortening mixture.
6. Transfer mixture to lined dish and put in oven for 40 minutes.
7. Remove promptly from oven and allow to cool before dividing.

Discussion

I was inspired by Brian Lagerstrom's video about developing what he considered to be the greatest brownie of all time. I then spent several months tweaking it until I was happy with it.

One of my first changes was to double the quantity of milk chocolate and cocoa and scale up the other ingredients accordingly, preferring round numbers/whole packets. Mrs Cosgrove prefers the colour contrast of white chocolate chips.

I eventually settled on vegetable shortening instead of his butter and olive oil. The result is that the brownie melts in the mouth not the hand, and is not greasy to the touch. Lard was similarly effective but had a challenging odour unless one left the brownies out to air for 24 hours.

I can't remember why I reduced the proportion of flour, but it seems to work!

A porcelain dish resulted in a more even bake than a metal tray.

A baking time of 40 minutes resulted in the optimal balance between fudginess and rise for me. If you prefer your brownies more fudgy and don't mind them sinking in the middle, feel free to reduce the baking time. If you prefer more rise and can tolerate drier brownies, bake for longer.

Though I say it myself, these brownies are now a firm favourite in our family, provided my five year old daughter leaves any for the rest of us!

Address to RCGP AGM 2023

RCGP's 2023 AGM was unusual in that several resolutions proposing constitutional change were presented without first having been scrutinised by Council.

Mercifully, a strong attendance including many former Council members and Officers refused to pass the two most contentious resolutions.

I spoke against resolution 6 (which proposed that College members sitting on Trustee Board need not also be Council members):

Trustee Board needs to be more not less accountable to members, who frequently perceive they have little influence over decisions taken on their behalf in ivory towers. All members with greater influence in our college, whether Officers or members of Trustee Board or of the Governance Committee, should in my opinion have their personal mandate validated by election of faculty boards or members every 3 years, just like the majority of Council members.

My understanding is that it had initially been proposed to allow Trustee Board to choose its own chair, and to determine the term of Trustee Board members. This was concerning. Thank you, Michael for having clarified this matter.

Members and faculties elect representatives to Council in the belief

1. that they can influence the membership value proposition, and
2. that they might influence policy by presenting motions from their consituencies to Council. I am aware of one such motion that is currently being blocked by Officers.

Safeguards need to be maintained to ensure accountability of and accessibility to College Offices and boards and committees, including Council: I am concerned that there appears instead to be a desire to limit accountability and accessibility, illustrated in my view my resolution 6.

Miscarriage

 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.

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.

Notes from RCGP Council meeting 23 November 2019

Transparency

For the first time, members have been able to access on the RCGP website proposals for approval by RCGP Council.

Readers of this page will know that this is something I have been pushing for ever since I joined Council.

I am grateful to Victoria Tzortziou Brown, Jonathan Leach, other Officers, and staff including Michael English and Martyn Schofield who worked so hard to overcome technical and other challenges to make this happen.

Hopefully papers will appear online more than a few days before the next meeting!

Brunei Serious Event Review

Thank you to Simon Gregory and the team for this thorough and considered piece of work. I would like to make suggestions following on from three of the recommendations.

Recommendation 16
Classification and publication of policy papers and minutes is a matter that Kirsty Baldwin and I gave some thought to when we presented to Council our first paper on balancing transparency with information security in June 2015.
I see that the cover page of Council papers has had a bit of a make-over since our last meeting, to include - no doubt coincidentally - some of the features that we had proposed. I would suggest the addition of:

• Version numbering
• A field explaining why the paper has been restricted or not,
• And another field suggesting how the distribution might change after approval.

My understanding was that the vast majority of approved papers are not restricted, and it would be great to see these made available online in an easily accessible and searchable format.

Recommendation 17
I welcome the suggestions to improve the accuracy and detail of minutes. Necessarily however, minutes cannot be published until they have been approved by the next meeting, a delay that hinders transparency. Any interest a member had in the meeting may well have long since dissipated by the time the minutes are published!
I note the observation in this report that minutes, not being a Hansard-style verbatim transcript, tend not to capture the full range of views expressed.
We are starting to get more of a flavour of Council debate from the contemporaneous tweets that are put out.
Most of us here write our own notes of Council meetings and share them with our constituents, and the Hon. Sec. publishes a post-Council letter.
I have a radical suggestion that may help to combine the advantages of all of these approaches, but would not replace any of them. Why don’t we operate a Wikipedia-style collaborative system of note-keeping that each of us can use to record our notes on a voluntary basis. Viewers can they choose to read everyone’s records or just those of individual Council members. We would need some IT support, but I’m fairly sure the technology is available and the software is free of charge.
We would need to make clear that these were merely the recollections of individual members and not approved minutes, but it may help to capitalise on any interest generated by a particular meeting and enhance transparency.

Finally, I note and respect that this paper has been marked confidential. I trust that my suggestions, being generic in nature, would not be considered sensitive.

Strategic Plan

Could I suggest that we add “Equity” to our list of values? It might be implied by some of the other items, but equity really is central to the list-based work of GPs, who are perpetually aware of opportunity cost: while we are helping one patient we are not available to our other 2,000 patients; this is one of many reasons why we must guard against overdiagnosis and unnecessary medicalisation.

Brexit update

I’m grateful for all the work that is being undertaken relating to Brexit. As the summary reminds us, Council called in November 2018 for a “people’s vote”. Could you please reassure me that College will continue to campaign for a people’s vote in line with our policy?

International Strategy

Would it be possible to incorporate the recommendations of the Brunei Serious Event Review into this overview? I refer not least to recommendation 6 of the Brunei report calling for annual reporting of international visits, including rationale, expenses and funding. It would be good to receive the first such annual report in November 2020.

Recommendation 9
I’d like to make a suggestion arising from recommendation 9 of the Brunei report, but it seemed more relevant to the international strategy.
I note the concerns that social media activity might not be representative of members. I think this is something that all of us here grapple with, especially perhaps those of us who are nationally elected.
I note from the international strategy update that our international strategy is due for review in 2021.
I note from the Trustee Board minutes that international members comprise 6.3% of our membership, and yet one gets the impression - rightly or wrongly - that more than 6.3% of our activity is directed overseas.
Much as the Brexit 2016 referendum has reminded us of the pitfalls of direct democracy, might I suggest that we find out what the views of our members actually are regarding our international strategy before 2021? I would suggest a formal consultation of all members, probably mainly qualitative, to determine to what extent they feel their College should support activity abroad, and how international and UK-based members respectively should influence our policy. At the same time, we could similarly take the opportunity to test members’ views on expanding membership to non-GPs.

Prohibition of the defence of reasonable punishment

This was a motion from RCGP Wales calling for physical discipline of children to be criminalised. I had not planned to speak to this item but on hearing the debate was alarmed by potential for misunderstandings and false accusations. I therefore announced that I whilst I would want parents to receive enhanced support in using non-physical disciplinary methods, I would vote against criminalisation and associated further state-intrusion into family life.

My view was clearly in the minority, as the motion was passed almost unanimously.

Declaration of interest as a condition of registration

It is an honour for me to second this motion. We should be immensely grateful to Margaret for her indefatiguable resolve over many years to make declarations of interest by doctors routine, public and now universal.
From a practical point of view, to have just one central register of interests could save each of us the trouble of remembering to update the register of each organisation we are associated with - and the potential embarrassment of forgetting to do so.
New members of Council - welcome! - will no doubt have been reminded of the Nolan principles of public life to which we must adhere. One of these seven principles is “openness”.
I’m sure no-one in this room, therefore, would hesitate to show leadership in this area. I’m hopeful, therefore, that we will embrace this proposal enthusiastically.

The motion was passed almost unanimously.

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.

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.

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.

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.

Notes from RCGP Council meeting 24 November 2018

Brexit

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.

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.

Sepsis

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.

Brexit

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.

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.

I think we need to move away from GPs being expected to ‘administer’ advice to their patients. If it doesn’t require us to need a medical licence it’s shouldn’t be our role.

— Clare Gerada #FBPE (@ClareGerada) June 23, 2018

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.

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.

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?"

Notes from RCGP Council meeting 18 November 2017

Council Standing Orders

Concerned about a clause (15B) which allows motions to Council to be rejected simply because they are poorly-worded, I suggested the following alternative wording:

Suggestions for improvement or clarification may be fed back to the proposer, who may ask the Chief Executive to withdraw the motion at any time before the meeting.

Trustee matters

Noting the increasing profitability of RCGP Enterprises and Conferences Ltd, I received clarification that the profit of the RCGP annual conference in 2017 was almost half that of the conference in 2016.

As is routine, the minutes of the Trustee Board meeting quoted the membership retention rate, currently 94%. I asked the Chair of the Trustee Board in future regularly also to provide a breakdown of retention rates at different levels of seniority, including of trainees (Associate in Training - AiTs).

The wider team in General Practice

I advised that for each role in General Practice:

• core competencies should be defined and kept under review
• there should be a regulatory process (currently only voluntary for Physician Associates, for example)

RCGP CPD Strategy

Responding to the RCGP draft CPD strategy, I received clarification that RCGP's publishing house, RCGP Books, is no longer active.

Notes from RCGP Council meeting 24 June 2017

Physician Associates

Council did not approve the following draft position:

The RCGP is committed to working with governments across the UK, physician associates and our members to ensure that physician associates in general practice work safely and effectively as part of a GP-led multidisciplinary team to support and provide continuing, high-quality, integrated patient care. Physician associates should be seen as new members of the clinical team, complementary to GPs, rather than a substitute for them.

I made the following points:

Having canvassed opinion on this matter, I can say there is still considerable anxiety amongst GPs on this matter. Hearteningly, some critics have latterly been working with physician associates and found that, with tightly defined roles, they are valuable members of their team.

It is vital that the optimum role of physician associates in general practice is defined carefully, as well as resolving issues including regulation, standardisation of training, continuous professional development and revalidation.

There is much anxiety about the role of physician associates in general practice, how efficiently they consult, and how burdensome it will be for GPs supervising them in terms of time and carrying risk.

By virtue of medical undergraduate training, on-the-job acute hospital experience and GP specialist training, GPs are second-to-none amongst professionals at managing undifferentiated presentations.

The literature I have found demonstrates that PAs are at best as cost-effective as GPs (without considering costs of supervision) when consulting a pre-selected, less complex cohort. Indeed, that cohort (triaged by receptionists) was also less affluent, which reinforces concerns about accentuating health inequality.

I would suggest that our position make reference to cost-effectiveness rather than just effectiveness and that any impact on colleagues (thinking about costs such as time and risk) be fully mitigated.

RCGP Sponsorship Policy Review

In response to a paper setting out the terms of a review of RCGP's sponsorship policy, I made the following remarks:

I am uncomfortable at the proposed distinction between commercial and non-commercial sponsors. I am reminded of the aphorism "The road to hell is paved with good intentions." Many organisations, both commercial and non-commercial, have laudable intentions, regardless of funding.

It is more important to look at the objectives of corporate sponsors: if their objectives could benefit from a change in clinical practice by RCGP members, we must ensure that that objective is aligned with policy previously agreed by Council and that RCGP retains editorial control.

RCGP Leadership Strategy

I welcomed the proposals to ensure the delivery of leadership, management and business skills during GP training. I asked how it would be funded (and was advised some funding would be sought from the King's Fund) mindful that there might be other priorities for any RCGP funding.

I sought reassurance that any leadership, management and business tasks assigned to trainees would be of high educational value and I questioned whether that included minute taking (as suggested in the paper).

Report of the Overdiagnosis group

A report was received from the overdiagnosis group of their excellent work over the last 3 years. They call for training for College employees to ensure that the 5 tests of overdiagnosis be applied consistently and rigorously to all College policies, that evidence-based medicine and shared decision making should be given higher priority in all medical undergraduate and GP education, and that the Overdiagnosis group should work more closely with the RCGP Clinical Priorities programme.

Screening not recommended by the UK National Screening Committee

Council received an excellent paper describing the ethical difficulties surrounding screening (testing apparently healthy individuals) which has not been approved by the UK National Screening Committee. There was a difference of opinion between one Council member who suggested that screening of individuals at their request, or of high risk populations at the discretion of local clinicians should not be discouraged. In contrast, the view of the authors of the paper remains strongly that patients should only be offered the choice of cost-effective tests.

What's So Good About GPs Being Independent Contractors?

GPs are not directly employed by the NHS. GP principals (who usually work in partnerships and may themselves employ other, salaried, GPs) are contracted to NHS England for the work that they do. They are free to undertake private work (such as providing insurance and legal reports) but the vast majority of their work is for the NHS.

By Diliff - Own work, CC BY-SA 2.5, Link

Therefore, GP principals are in the unique position of deriving the vast majority of their income (from which they will also have to pay for their expenses such as nursing and administrative staff) from one employer but being independent contractors.

GP principals have a great degree of autonomy over how to run their practice (which NHSE and governments may find frustrating) and are motivated to work long hours (sometimes longer than healthy) completing the work their patients need from them. They can be well rewarded but also carry the risk for employing their staff: if the practice fails financially, they can be personally liable.

As such, GPs as independent contractors offer unparalleled value for money for the NHS.

Unfortunately, in recent years, the work required has mushroomed and the funding, as in much of the public sector, has been squeezed. As such, the responsibility, workload and risk has been daunting for many. Many GPs have left the workforce and not enough have been trained. There has been a reluctance in some cases to share profits with newer colleagues even if they wanted partnership.

Consequently, unless substantial new resources are forthcoming, the model of employing GPs as independent contractors is under threat.

In the report of the House of Lords Select Committee on the Long-term Sustainability of the NHS, it was suggested that the independent contractor status of GPs as a model of funding was "not fit for purpose" (page 23 para 71). This is only because of years of the model being sabotaged, some would argue deliberately.

What is urgently needed is proper funding for General Practice, otherwise the ICS model will be only one of the first casualties. Certainly, without new resources, we will in the interim need to find new and less efficient ways of working, probably using directly employed GPs and other staff.

My declarations of interest
I have been a GP for nearly 13 years, of which 4 have been as a partner of a large multisite partnership (Midlands Medical Partnership). I am currently a salaried GP at Sandbach GPs, Ashfields Primary Care Centre and am looking for a partnership to join, as I believe in the ICS model and that it has a future. I am standing for re-election to the Council of the Royal College of General Practitioners.)

Postscript 30 April 2017

According to a poll of nearly 850 GPs run by +Pulse Today, 57% believe the partnership model has no long term future and only 20% believed it would still exist 10 years hence.

Notes from RCGP Council meeting 24 February 2017

Storm Doris notwithstanding, there was a packed agenda. In a departure from tradition, education and innovation items were considered before politics, which allowed for more focus on the former.

Faculty Finance

I asked for some detail relating to the implementation of a change of administrative policy that had caused concern in my Faculty.

Referral management

I welcomed an excellent paper from the ethics committee summarising not only the limitations of referral management but also of the drivers of increased activity and financial pressures that are often blamed unfairly on GPs.

They reached the conclusion, important in my view, that prioritisation should be explicit, even though this is politically unacceptable. This supports my long-held view that, as well as healthcare funding, the electorate must consider the remit of the NHS. I called for College to campaign for prioritisation to be considered explicitly, perhaps as part of the ongoing Put Patients First campaign.

RCGP Clinical Priorities 2017-2020

Council approved the following clinical priorities: cancer (to March 2022); liver disease, mental health, physical activity and lifestyle, and sepsis (to March 2019) as well as a number of 12 month "spotlight projects".

I questioned how the recommendations of each project would be weighed against the five tests of overdiagnosis agreed by Council in 2015. It was agreed that the RCGP Overdiagnosis group would be kept updated on the work of the Clinical Innovation and Research Centre.

Fellowship and beyond

A discussion paper was presented on ideas to improve the uptake of fellowship across the demographic of College members, and College might support continuing professional development for fellows.

I reiterated my view that fellowship should be open to all GPs, including those who are not existing RCGP members. I also expressed concern that a CPD programme might lead to "higher" designations of fellowship, thus devaluing fellowship itself.

*update: I have since joined the FRCGP short life working group seeking to inform policy in this area.

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.