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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)

  • DrRubbishBin

    "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."
    really really really good article. you need to know what normal looks like to be able to spot what isn't . This isn't talked about enough and is basically one of THE most valuable skills a GP has. The absence of this ability is why specialists can sometimes totally miss the point. If we only ever see the ill we will forget what ISNT important, and everybody will be worse off

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  • We need to think long and hard what we remove from the GPs workload. And I agree, part of this is about protecting the GP, and making the job tolerable. Pill checks, waxy ears, UTIs. Some of this simple stuff gives us a lighter moment in a day filled with stress, decisions and complexity. Especially if you have an appreciative patient with it. Take away the lighter stuff, the patient appreciative of a simple remedy, and you leave a GP despairing at the seemingly endless intractable problems. I have said this before - we do not need to be the providers of low level mental health services. This would remove a huge burden from the GP. Patients could see trained mental health practitioners who could dole out citalopram just as well as I can, and they could have a closer working relationship with the mental health services and psychiatrists when needed. I had approximately 2 weeks teaching in psychiatry and 1 hospital placement as an SHO. This could easily be replicated for mental health workers with the back up that higher risk patients (poly pharmacy, older etc) could be seen by a GP with a special interest in mental health working in the same team. Give these teams half an hour appointments, and the resources they need and you could remove 10-20% of the GPs work load, and a great deal of stress associated with our inability to satisfactorily refer into MH, or engage support for these patients.

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  • Vinci Ho

    (1)The design of the GP appointment system needs a redesign .The truth is 10 minutes are only suitable for dealing with UTI , chest infection , vomiting & diarrhoea etc . If these cases are to be taken over by nurses , pharmacists or physician assistants , the ‘complicated’ cases left behind can only be dealt with by GP 20 minutes or beyond . Common sense .
    (2) Exactly what is the real job description of 21st century GP? That needs in-depth pondering . Gatekeeping has gradually become obsolete because the referral system onto secondary care is fundamentally broken . In fact , we are expecting more workload coming towards general practice from hospitals whether we like it or not . There are not enough specialists especially like radiologists , psychiatrists , geriatricians, A/E physicians etc. realistically .
    The ideology of PCNs is more for STP and ICS(integrated care system) to use for solving the crisis in secondary care than general practice. Arguably, if huge amount of resources came with that , the whole thing could , perhaps , be revolutionised . Genius or imbecile, this is at least ,what some are believing right now .
    (3) The system does not ‘fancy’ generalists anymore . It wants more diagnosticians , low level specialists and therapists in community . Following this direction of thinking, it is not difficult to understand why hospital consultants are only spending time dealing with cancer cases , for instance . Hence , referrals got bounced back and GPs are left with all the potentially least life-threatening conditions . One can argue that the system is set to ‘protect’ and shield the hospital specialists from GPs .

    Yes , we( GPs) are traditionally the dumping ground of conditions and cases secondary care refused to deal with . The difference in 21st century is the golf post has been moved even further away . How GPs can develop the skill/expertise and find time to cope with this exponentially increasing, dumped workload , the government, DHSC , NHSE etc has not got any f***ing clue .

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  • Vinci Ho

    Hence , referrals got bounced back and GPs are left with all the relatively less life-threatening conditions.

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  • I enjoy working as an OOH GP
    Granted the hours are anti social but I do see lots of variety. Some simple things as well as complex, and things I have never seen before.
    I feel I am doing the job I was trained for not spending half my time on MOLV (meetings of limited value) and filing pathology results, managing other clinicians and trying to cope with the increasing demand for appointments
    I agree delegation of all the simple stuff doesn’t work well and de skills us.
    Perhaps the lesser skilled clinicians could take all the histories from the complex
    Patients and We can spend 10 minutes completing the assessments?

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  • Brilliant article Shaba
    Truth in, and between every line
    Hell ... gouging away at the pinnacle of your expertise leads to burnout, working in fields of greatest clinical and medico legal risk.. sitting there to be shot at by the snipers who love to take us down.

    I still like the whole holistic thing, still do some phlebotomy .. because I like to! and it’s all useful patient contact.

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  • we can't turn back the clock and be 'proper GPs' because the system won't pay enough of us an appropriate hourly rate to do things properly.
    General Practice wasn't designed to work with. mostly patients with multiple complex problems and hardly anywhere to refer to.
    So the whole system needs redesigning without GPs.

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  • Does practicing at the top of our licence mean we can tell politicians and other health care professionals to get lost when they say GPs are best placed to:
    - Do welfare checks
    - Check the central heating
    - Address loneliness
    - organise blood tests
    - coordinate social services
    - fill in referral forms
    - Address DNAs or bounced referrals

    None of those tasks are working at the top of our licence -and all those tasks should be shelved and passed on to someone cheaper. The ONLY reason they are done by a GP is that the unique way GPs are paid means that it seems to come across as 'free' if the work lands at the door of a GP.

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  • GPs have different experiences and capabilities and should be able to practice within their comfort zone like true professionals in Australia. We are not stupid. If we mess up then the patient can always sue us. We do not need the RCGP restricting or limiting us. We are adults. We are professionals.

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