As a GP very near retirement I have the advantage of historical perspective even though I am not currently involved.
My concerns are more about the content of general practice than the method used to assess it. The exam has been obsessed with the consultation for decades, quite appropriately two decades ago, but (though still of vital importance) less central now that the content of primary care has shifted so much. Dealing with complexity is now the most challenging aspect of primary care and the importance of the GP role as conductor of the diagnostic/therapeutic/caring orchestra needs to be moved to the epicentre of the MRCGP exam. This involves holism in the traditional sense, but with the addition of ensuring the unified working of the other health and social care professionals to avoid gaps in care, wasteful overlap or, worst of all unknowing clash of incompatible interventions. The challenge of therapeutics has never been greater, and cannot be totally relegated to pharmacists or nurses or hospital specialists. The only person with the complete therapeutic score on his/her desk with a knowledge base to evaluate it is the GP. And this means that GPs need to have a much more extensive knowledge of therapeutics than has previously been necessary. Team working has always been a characteristic of quality primary care, but teams are now bigger, more diverse and often multi-sited and multiagency. Taking global responsibility for the patient, especially those who lack capacity, is essential to avoid fragmented care, and the GP is the obvious and most appropriately skilled person to take this role. But so doing requires formal continuity of care, which is under threat from part-time and casual working health professionals. Organisation of practices so as to provide continuity of care in the face of discontinuity of staffing is one of the most pressing problems. It is achievable but requires sophisticated practice management and an ethos of joint working. Out of hours care has become a black spot in primary care, a casualty of underfunding, privatisation and the loss of GP direction. Quality has suffered, and the lack of investment in academic study of out-of-hours care means that there is little evidence that can direct the organisation and provision of service. Yet the use paramedic response teams in this area leads to waste, unnecessary hospital admission and poor quality holistic care. General practice must aim to take back control of this area of care, and the membership exam needs to recognise its importance.
These are difficult times for general practice, but if we are to preserve our discipline, which is capable of providing high quality patient-sensitive, effective and efficient care at remarkably low cost, my successors need to focus on the areas of care that generalists are most suited to provide. We must also ensure that the high standards of the MRCGP exam are relevant to the job description of sort of GP needed in the future.
CQC is behaving like a cast in search of a play. They obviously don't have enough proper work to keep them occupied.
GP regulations always used to say that the doctor SHALL [not can, may or if the mood takes him/her] any medicines required for the patient on the form provided by the Secretary of State . Unless these have changed, this suggests that the doctor is obliged to prescribe and would be in breach of ToS if he/she did not. The CCG or even NHS England or even the Minister himself could not alter this requirement without a change of the Terms of Service.
The trouble with the CQC is that its ethos is to judge rather than to improve. Its replacement (TICS? - Team for Improving Care Standards?) needs to be be judged itself on its capacity to improve practices rather than to condemn them. It should be locally rather than nationally based and be able to look at the care received by patients in terms of accessibility and acceptability of service but also relevance to need, efficacy, efficiency and (most important of all) caring and quality in consultation. It should only be condemnatory if a practice is not willing to change (given appropriate resource). And it should have money and training resources for practice development and improvement. It should already have been invented by the RCGP because quality of care should be what the College is about. The fact that it hasn't is a serious criticism of the College.
The first problem with the CQC is that it makes quality judgments on things that can easily be measured rather than the things that matter most. The second is that it has no facilitative function. There are inevitably a few GPs and practices that are incompetent or even bad and these need dealing with. But the overwhelming majority are trying to produce a good service in spite of the constraints around them and the shortcomings of their own teams, individuals and resources. The CQC should be helping practices that underperform to develop and improve their services rather than slagging them off. When a patient drinks too much eats too much or fails to care for himself we don't tell him to go away and not darken our doorstep. We try to help him rebuild his life and turn himself around. That is what doctors are for. It looks as though Professor Field has forgotten this. The CQC has an attitude problem and it should have a GP leader that has the strength to change it.
QOF has changed general practice for the better and has provided an important justification for the long term continuance of our discipline. BEFORE QOF general practice was (quite simply) about what happened to come in through the door. AFTER QOF general practice was about continuing and holistic care of every patient on the list with a chronic or potentially chronic condition. It is true that many practices before QOF offered quality care to all their chronic patients, but this was far from universal, and most did not chase or encourage every one of their at risk patients to seek care. For over 50 years we had identifiable lists of patients, but did little to ensure that our care covered everyone at risk. When at last we were paid (and had the technology) to provide quality universal service and continuing care, we stepped up to the plate and changed the very essence of how we practised. QOF was sometimes barmy and ill-advised in detail, but in broad principle it worked and provided value for money. Let's continue to tweak it, but ensure that each additional task is adequately resourced. Abolish QOF and the money that pays for it will… just disappear into some daft politically inspired nonsense that will neither help our patients nor recognise the work we do.
Having spent the last 20 years working with CLINICAL pharmacists, both in research and in practice, (not community pharmacists in their chemists' shops) I am familiar with their range of knowledge and skills. Their strengths lie in their knowledge of pharmacology and therapeutics, their comfort with detail (GPs tend to paint with a broad brush!), Their knowledge of drug hazards and interactions and their readiness to listen to and address patients' ideas about their therapy. They are particularly good at medication review of patients with chronic disease (and this is well evidenced). They are also team players and learn from and teach the rest of the team.
Unfortunately they are is short supply, but the next generation of pharmacists who emerge from training with much more clinical skills are finding jobs in the retail industry fewer in number and less well remunerated (as they are replaced by dispensers). We should try and grab them whilst we can. If CCGs will allow practices to use savings on prescribing to employ them, this can be a win-win.
"Who is wise? The one who learns from every person." (Simon Ben Zoma, 2nd Century Sage Ethics of the Fathers.)
As a locum GP now retired from my long-term Practice, I can perhaps view the new contract with a wider perspective. The important issue (which I have not seen reported on in any of the press reports) is the question of Target Net Income. If this concept is still retained in pay negotiations, GPs as a whole have some protection against market forces (though there will be individual winners and losers). If not, the future is very worrying.
As regards QOF, I guess this has achieved its major (and most important) objective. It has changed forever what general practice is about. Before QOF, general practice was essentially about what came in through the door. The College and enthusiastic GPs practiced some population-based care, but this was not consistent across all general practice. Our responsibilities now extend to continuing care, even of those who do not present. We have utilised the unique UK general practice asset of the registered list. We have reduced mortality and morbidity. We have improved our patients' health. We should be celebrating this… and so should the Government.
Governments will always govern. This one seems to be particularly insensitive and autocratic and particularly unwilling to embrace evidence. But it will not be here forever, and there will be another one behind.
Those who support charging for consultations are politically naive and cannot see the wood for the trees.
There are 6 outcomes of charging. All are negative:
1. People who need help will be inhibited from seeking it and present later with their important illnesses or will go to A+E, thereby exacerbating the hospital crisis and reducing the workload of GP, spelling the beginning of the end of general practice as a job/discipline (because if the NHS can manage without general practice it will stop providing it).
2. People with chronic illnesses will avoid the doctor, so that the quality of longterm care for IHD, diabetes, mental health problems and asthma will deteriorate... just when we have achieved measurable improvements in morbidity. The poor will get sicker and the rich will continue to thrive. Is that what we want?
3. The worried well will happily pay the fee and expect spectacular and instant service for their money. They will have longer and more frequent appointments. They will want some beef for their buck. They will also be less ready to accept advice without prescription. "I have paid for this consultation!"
4. The government will reduce payments into general practice, arguing that GPs cannot expect to be paid twice for their work. At the same time they will put a limit on the charge that can be levied and exempt the very people who create the greatest workload. GPs will be no better off financially, and probably worse off.
5. Virgin, G4S, Tesco and Serco will offer a flashier form of GP with high prices, doctors that never say no, paying its GPs low sessional rates for working unsocial hours. Patients will be attracted with low (loss leader) insurance rates at first. These will gradually rise, as will the profits. But they won's accrue to the GPs on zero hour contracts.
6. Proper general practice, with continuing care, sensitivity to patient need, support for the disadvantaged, health promotion, and clinical care unsullied by profit motive will be dead (like NHS dentistry and optometry), replaced by a cynical, grasping, greedy, tax-avoiding big business that sends all its profits overseas. We will have killed it.
As regards the fee that we should have to charge to maintain the infrastructure of general practice, including premises, nursing, equipment etc., with the added superstructure of a fee-collecting and complex accounting system and longer opening hours, my guess that nothing short of £50 a consultation could maintain the system.
I think we should be careful what we wish for!
Please join the petition against this silly idea:
They just don't get it, do they? Perhaps they don't want to. Bring back the workhouse, starving kids, slave labour!
Of course GPs must continue to be involved in helping people to decide whether they are well enough to work, and in certifying this view where it will help both patient and employer. It is disappointing that your above anonymous correspondents are so intent on reducing their own workload that they want to offload to anyone, however unsuitable. Patients trust their GPs (though perhaps not your second anonymous correspondent above). We are not paid by either the Benefits Agency or by their employers, so our view on fitness for work can be taken from the patient's perspective. (We ARE paid for sickness certification through target net income, but we are not under any pressure from the DH (yet!) to achieve any particular level of certification of fitness.) If we don't know enough about occupational health to advise our patients, it is about time we learned about it. It is far more relevant to general practice than a great deal that the rarer causes of B12 deficiency or peripheral neuropathy. In contrast to your cynical second anonymous correspondent, my experience in over 25 practices In Leeds and district is that many patients need to be persuaded to take time off, especially those with depression, or in whom their sickness is a threat to others' health, or indeed to their own health. Many feel intimidated by employers to stay at work when it is neither in their or their employers' interest that they do so.
As regards the question of whether the certificate should reflect fitness for current job or any job, this surely must depend upon the period of time of, the nature of the illness (whether recovery is to be expected, and whether the patient actually has a job to return to. If your above correspondents had myocardial infarcts or bowel resections, they would expect to take time off work (I hope) and have it certified by their GP, even though they might still have the capability to write a prescription or a sick note!
It doesn't matter what you SAY to the patient in tears... they are unlikely to hear or remember your words. It's HOW you respond that matters. And ten minutes is unlikely to be enough, so forget the clock. If a few patients have to wait a bit longer, so be it. One day it might be their turn to be desperate.
All you need to do is to listen actively and sympathetically. Make them feel that they are the most important patient you'll see that day... because they probably are. Encouraging to talk with the occasional opening up phrase... 'Would it help to tell me about it?' 'That must have upset you terribly...' 'What does your partner/spouse/colleague/friend say?' Be specific and ask whether there's anything you can do to help... but don't expect that there's much you can do.
You may not be able to change the patient's life... you will not be expected to. But everyone has their melting point and it's sometimes part of our job to melt with them. And if, at the end of a day with two or three weeping patients you feel like weeping too, go ahead, it may do you as much good as the patient.