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Independents' Day

Do you want to be stranded at the top of your licence?

Dr Shaba Nabi

All parents of preteens realise language is constantly evolving – just when you think you’ve nailed the lingo of the yoof, you are derided for getting it wrong.

Medical politics is faced with a similar jargon of evolving ways to describe GPs. A few years ago it was popular to refer to us as the conductors of an orchestra, marshalling an array of allied healthcare professionals plucking at their instruments.

This term didn’t really take off so now we are urged to practise at the ‘top of our licence’. But what does this even mean? A quick Google search tells me it’s a US term that refers to doctors doing what only doctors are trained to do and delegating everything else to other professionals. In practice, this means letting nurses, pharmacists and physician associates carry out some of the more mundane tasks like repeat prescribing and filing results; things presumably at the bottom of our licence.

A laudable aim, you may think, and what could possibly be wrong with it?

GP training is different from most other specialist training programmes in that we don’t need to have an encyclopedic knowledge of facts or keep a logbook of how many operations we have completed. Instead, we need to integrate a random constellation of physical, psychological and social symptoms, wrap them up with a bow and present them to the patient as a reassurance of normality. We dish out these comfort packages 90% of the time, but every now and again we have to delve deeper, and we only know when to do this because we’ve given out so much reassurance in the past.

Filing normal results is the kind of CPD that can’t be replicated in the classroom

If we only practise at the top of our licence, there is a real danger we will lose our valuable gatekeeper role, as all we’ll see is packages needing lots of delving, and we’ll soon forget what normality looks like. And if we are no longer a gatekeeper, what is the point of us?

It may be that you agree we should continue to see undifferentiated symptomatology to remain sharp, but you can see no reason to be filing normal blood results, reading hospital letters and signing repeat prescriptions. These are all tasks that can be delegated following a robust clinical protocol.

But the danger is that we lose out on the wealth of knowledge GPs have acquired through the feedback loop of referral and investigation. This is the type of continuing professional development that can never be replicated in a classroom. And aside from our lifelong learning, if my two hours of clinical administration were to be replaced with seeing another 12 high-maintenance patients, I know which I would prefer to be doing. A day bulging with multiple clinical contacts and nothing else is a day of emotional overload and the road to burnout.

But my biggest fear of all is that working at the top of my licence will mean the buck will always stop with me. If a patient doesn’t fit a guidance or a protocol, or if there are psychiatric or safeguarding issues, or if there is considerable risk associated with a scenario, I will be parachuted in to work at the top of my licence. But as far as I can tell, it’s because I’m the only one with a licence to kill.

Dr Shaba Nabi is a GP trainer in Bristol. Read more Dr Nabi’s blogs online at

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Readers' comments (19)

  • Licence to kill? Really?

    This is a wholly personal opinion but if one starts out pre-supposing that the constellation of symptoms are "random" then you are setting off on the wrong foot.They might be random, but 10 minutes and superficial knowledge are hindrances to properly evaluating whats going on. With a more complex patient populace, older and with multi-morbidity and the often overlooked fact that advancing age invariably means more pathology and oft-times subtle indicators of issues which are commonly not picked up. Late cancer diagnosis being a real-time indicator of what I refer to.

    "Robust clinical protocols" is a garbage phrase which fails to recognise that for example GP perusal of hospital correspondence is not great, and these "pathways" cannot be slavishly followed to fully extract the key information from the letters and is typically asking the junior James Bonds to perform a task they are not trained for.

    Bottom line- the system is fu##ed, bandaids don't work in the anticoagulated and bleeding system, the patients are the biggest losers and any personal satisfaction that one is doing the job to a standard one would wish for ones parents/kids is a delusion.

    There has never been a better time to be a GP, to quote one of our colleagues whose disingenuity and failing visual acuity must be of concern to his/her patients.

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  • An excellent article. Allied health professionals creaming off all the easy work is not the answer.

    BTW I am just finishing my clinic as a GPSI in dermatology. The consultant next door who is the "lead consultant" will only see 2ww as they are "most demanding of his skills". The fact they only take 2 mins and he spends the minutes in between doing telederm, which he gets paid another session for, seems more likely. We are mugs as GP's and should be striking for better terms and conditions.

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  • interesting Zil Dogo.... I work in Australia..... I guarantee that with an interest in skin cancer down here, you'll see and do more that a 'specialist' dermatologist in the UK does.... specialists aren't so special..... its where the RCGP let us down.... they let all the fun stuff get taken away from us... paralysis of fear at the top...

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  • Excellent article Shaba. Thank you.

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  • What a good article. I prefer my day to be full of minor illness and chronic disease, so that I can cope with the occasional patient who has the life threatening presentation, that I have to sort from the triva. No one can cope with full on high drama, all of the day. That is the way to burn out.

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  • Either 10 min appointments full of trivia or 30-45 min appointments ‘at the top of our license’. kind of a zero sum game on efficiency.

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  • I disagree about not having encyclopaedic knowledge. Encyclopaediae tell you a bit about everything, like a GP.

    Intentional misspelling for comedic effect.

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  • Microspecialisation and part time working is crushing general practice causing mutiple appointments and thus overloading the system, exhausting doctors, who respond by limiting their roles (eg the diabetic lead) making matters worse. We need to get back to being general practitioners.

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  • Agree with Shaba. We will just end up with all the TATT heartsinks, all the high risk stuff and the multi morbidity patients where a JUDGEMENT call has to be made and is not amenable to polyprotocolism. We will deskill very rapidly if we let other cream off all the rest. FIVE times in th past 10 years I have had a non physician flying protocol miss serious life threats because they simply don't have the training knowledge skill or expertise to think outside the box because they are doing medicine by rote rather than practice by pathophysiological principle

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  • Excellent article Shaba. Top of Licence working pre-disposes GPs to burnout. Seeing 40+ patients/day with a DOB before 1930 in the 10 minute tyranny is unsafe and unsustainable. There needs to be acknowledgement that you have a cognitive load beyond which the decision density is excessive i.e. we need an occasional infected toenail or pill check. If not, then we need longer with these complex patients. Having worked in practices where there are several ANPs doing an excellent job, a 16 patient surgery for a GP is exhausting.

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