RCGP chair-elect Professor Martin Marshall will take over the role in November, at a crucial time for the profession.The new contracts in England and Scotland are changing the whole nature of general practice.
How much difference these will make for grassroots GPs is another matter entirely, but the RCGP has been integral to the changes. Additional funding across the four nations, promises of extra GPs, the state-backed indemnity scheme and the removal of doctors from the Tier 2 visa cap were all introduced soon after the college exerted pressure.
Professor Marshall’s priorities during his tenure will therefore have a major influence on general practice – which is why he tops our Power 50 this year. Here, in his first interview since being elected, he tells Pulse deputy editor Nicola Merrifield why there is a danger of overburdening primary care networks (PCNs) and the importance of talking up general practice.
Pulse: What are most concerning issues facing the profession and how do you intend to tackle them?
Professor Marshall The biggest threat to general practice is workload. That’s been very clear in the time I’ve been a GP: when I first started I was probably seeing 20-25 patients a day, now I’m seeing between 50 and 60. It’s a dramatic increase in consultations, and probably more important is the increasing complexity of those consultations.
It’s about workforce, it’s about recruiting more young doctors into general practice. It’s also about talking up general practice. I think there have been times in the past where because things have been so difficult, we’ve talked negatively about it and that doesn’t create a good image for medical students or foundation doctors. The first five years are often the most difficult. We also need to think about the retention of doctors later on in their career, in their 50s and early 60s
How important is it for GPs to delegate to other general practice staff to ease workloads? The reality is that general practice is going to become more multidisciplinary, so we’re supporting the development of other professionals to take on some of the tasks that GPs have traditionally done.
The reality is that general practice is going to become more multidisciplinary
It’s a cultural challenge for GPs, who are used to doing just about everything and being all things to all patients, to recognise that at a time when there aren’t enough GPs – and that’s fundamentally important, there simply aren’t enough GPs – we have to be more focused about where we can add greatest value. I think, traditionally, people talk about GPs having to focus more on complex patients and that requires us to give up something.
How difficult will it be to recruit additional practice staff? That’s going to be a big challenge, because we know how difficult it’s been to get these additional 5,000 GPs [promised in 2015 by former health secretary Jeremy Hunt]. We’ve got 5,000 other general practice staff being recruited, focusing initially on pharmacists and social prescribers, but then progressively looking at mental health and other health professionals as well.
Some primary care networks even now are finding it difficult to recruit those. I’m sure we’ll get to the 5,000 [non-GP practice staff] because we’re already halfway there, but whether we’ll have enough people in all parts of the country, I think is an open question.
How far can primary care networks reduce GP workload? I think the potential of PCNs to reduce workload is significant. The reality is we have to see. Working at scale is desirable, it’s also probably the only pragmatic option available in order to keep a lot of the practices operating that need to keep operating.
Is there a danger PCNs will become overburdened with work? The ability of PCNs to actually deliver on their potential is entirely dependent on how much space they’re given to do it and I think NHS England is doing the right thing in standing back from PCNs and not mandating a whole set of new responsibilities, and I hope that it sticks with that. Because the biggest danger I see is every time there’s a new function, I hear people – almost everybody, when I’m in meetings with NHS England or with the commissioners – saying, ‘PCNs will deal with that’.
With networks, we’ve seen this before with new organisations – they have not been allowed to bed in
At the moment, most PCNs are settling in, they’re trying to sort out their financial arrangements and staffing. But I hear people saying things like: ‘General practice needs to do more work around social determinants of health, getting into the public health space.’ I happen to believe that is the right thing to do. But we’ve seen this before with new organisations – they have not been allowed to bed in and as a consequence they’ve struggled.
How well prepared are clinical directors to lead networks? Some of the new clinical directors being appointed by the PCNs are really exciting, but quite a few are new leaders, some of them quite young doctors. And the worst thing that could possibly happen is they get sucked into the system, spend all their time going to STP meetings, and are not able to focus on what they need to focus on, which is supporting their peer group to care for their patients.
I see some parts of the country where the PCNs are building on the structures, governance and relationships that have gone before and they’re really flying and really doing amazing work. In some parts of the country it will work well; others will require more support and help and that’s where we as a college come in.
To what extent are digital services able to reduce demand on GPs? As a college we welcome and are even excited about the potential of technology to support general practice. We recognise completely that the standard model of general practice, the 10-minute face-to face patient consultation, is not long enough but it’s not the only way of delivering care.
Patients would much rather that their online consultations were provided by staff whom they know
There’s lots of ways to deliver care, and perhaps we need to be a bit more explicit about what requires a face-to-face consultation and what might not. We see the commercial providers of these products as having a high profile, but we don’t think they’re going to provide care for the vast majority of patients. Patients belonging to a practice anywhere in the country would much rather that their online consultations were provided by staff whom they know, the doctors and nurses who are already in the practice.
How far should commercial services, such as Babylon’s online video consultation service, be used as a model for NHS general practice? There are some things commercial providers have done well. They have pushed the agenda – it’s happening faster as a consequence of them coming into the territory. Training their doctors is an example of what they do well. I’m sure that’s something the NHS will be able to learn from. We need to accept that these new technologies require education and training for the workforce. However, I just don’t think that they’re the future.
The RCGP has been working to tackle overdiagnosis. How big a threat is that to general practice? Our job as GPs is to get the right balance between underdiagnosis and overdiagnosis and we have spent so long, particularly through the QOF, focusing on the underdiagnosis issues that we’re only in recent years recognising some of the unintended consequences that can arise from forcing a medical model on patients. The college is very sharp about this issue and we push back when we see programmes being introduced that don’t satisfy the criteria set out by the National Screening Committee.
We have spent so long focusing on underdiagnosis that we’re only [now] recognising unintended consequences
There are some examples of this, like atrial fibrillation screening. We don’t have the evidence yet. There is a major trial going on at the moment [the SAFER study] which will be reporting in a couple of years’ time, to find out whether systematic population screening for atrial fibrillation is a cost-effective intervention. At the moment we don’t have that evidence, so we’ve pushed back on NHS England when, through the academic health science networks, it has been introducing some of those screening programmes in some parts of the country.
Professor Marshall on recent RCGP controversies
We probably shouldn’t have invited her. She’s a ‘shock jock’ and we’re a sensible, professional body that wants to have real debates of substance. So we want people on our panel who would contribute to that, not people who make alarmist statements, or statements that are not in line with our values.
Whether the RCGP acted quickly enough to revoke the honorary title it awarded to the Sultan of Brunei [the calls came after the country introduced a law making gay sex punishable by death]
Our members could see a problem and they wanted quick action, and that always runs counter to what is possible in a large organisation that is trying to deal with a complex problem. We have a responsibility to the GPs in Brunei who are being supported, irrespective of the Sultan or the political regime that’s there, and we need to be absolutely clear what the implications of addressing what was a completely unacceptable problem were for those people before we were able to take a positive action. So that’s why it took us rather longer than people would have liked.
Accusations that the MRCGP exam is discriminatory due to lower pass rates among BME graduates
The most important thing that we know, from the evaluations that we’ve done and from a growing number of evaluations, is that there is no evidence at all that it’s the exam or the exam process that is discriminatory. We know that there’s differential attainment. We regard that as a serious challenge for us, something that we need to understand better than we do at the moment, but there’s no evidence at all that it’s the exam, or the process of the exam, which is the cause of that.
Family Married to Susan
• 1987 Graduated MBBS from the University of London
•2017-present Programme director of primary care, community care and population health, UCL Partners
•2016-present Vice-chair (external aff airs), RCGP
•2014-present GP, Liberty Bridge Road practice, Newham, London
•2012-present Professor of Healthcare Improvement, UCL
Other interests Hiking, cycling, kayaking with family and friends