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 20 June 2015

The agenda for today's meeting was packed, including, I am pleased to say, a paper on transparency which I wrote with +Jonathan Leach and +Kirsty Baldwin.

#OpenRCGP discussion paper:
Balancing transparency with information security

"First of all, I would like to thank my co-authors Jonathan Leach and Kirsty Baldwin for their invaluable input, and also Officers and staff, including Paul Rees, for their enthusiastic encouragement.

"I have been receiving Council papers for over 10 years. Throughout that time, I and colleagues have had some uncertainty about how confidential individual College documents are, and therefore a frustration that we did not feel free to share them with other members.

"There are some practical details to be worked out. We are looking for feedback from Council on our proposals to allow us to continue developing these proposals

"Our proposals therefore form two main strands:

• clarity as to exactly how confidential individual documents should be
• reduce the risk of unwitting leaks
• and minimise unnecessary restriction
• this builds on good practice by groups such as the Trustee Board and the Planning and Resources Committee
• publication of Council documents
• moving from a position of sharing with members only what we are obliged to share, to sharing with members as much as possible so as to improve engagement and foster a sense of ownership commensurate with their membership fees
• builds on the decision at the Council meeting in February 2015 to publish minutes
• as part of this, our 3rd proposal is for a staff observer to Tweet from Council
• builds on Council’s views on Social Media use during Council meetings aired in September

"We would be grateful for Council’s thoughts on these proposals.

My understanding of Council rules as they stand is that I am free only to disclose my comments, hence the one-sided nature of my notes here.

"New deal for General Practice"

Jeremy Hunt had set out what he described as a new deal for General Practice the day before. I have already analysed this announcement on these pages and found it wanting. I told Council that it contained neither anything new nor a deal and that I continued to be dismayed at his apparently fixed idea that healthcare is a commodity. Indeed, his assertion that he could not change consumer expectations was particularly disappointing and he is probably referring more to an unwillingness to risk losing votes by being honest with patients about what they might reasonably expect from the NHS.

Overdiagnosis

I welcomed a paper on overdiagnosis from +Margaret Mccartney and +Julian Treadwell on behalf of the RCGP Overdiagnosis group. It proposes tests to be applied to every policy proposed by RCGP. I advised that these include a test of opportunity cost: i.e. if new work is proposed, what old work should GPs stop doing?

GP workload & fatigue

I welcomed a paper linking GP workload with patient safety. I warned that there is a fine line between making such a link and acknowledging that GP is relatively low risk, without fuelling further risk intolerance, which itself has been a major driver of pressure on GP services.

I warned that making a link to "missed and delayed diagnoses" implies a precision and urgency of diagnosis that is often not appropriate in General Practice and risks encouraging over-investigation, -diagnosis and -treatment. I recommended instead referring to "reduced quality of diagnosis" and "unacceptable delay in treatment."

Skill mix in General Practice and Primary Care

I warned that many members are nervous about proposals to increase the skill mix in General Practice. We must reassure them that we are the Royal College of General Practitioners and will put their interests first.

I advised that changing the name, remit or democratic processes of College would be a big decision and should only be considered after a full a careful consultation with the membership as a whole. Until then, the involvement of non-GPs in the democratic processes of College should be limited to observing.