Pandering to the vocal classes

I found myself nodding in agreement with Dr Mohammad Razai’s piece on the trouble with single-issue campaigns. As a GP training programme director, I am familiar with the outrage from various special interest groups about the lack of training for GPs in the areas of safeguarding, paediatrics, mental health, perinatal health, domestic violence  and neurodiversity – to name but a few. The usual kneejerk emails come out of Health Education England instructing us to include these areas in our training programme, so we add a tokenistic session to keep everyone happy.

Yet the fundamentals of the GP contract and partnership issues feature nowhere in the RCGP curriculum, and trainees exit with little idea of how GP services are commissioned or funded, or how LMCs can help with these. 

The narrative is always the same: GPs are rubbish and know nothing about condition X, and more must be done to raise awareness and improve training. This was brought to a head by the recent documentary from Davina McCall, Patron Saint of Menopause. 

Now there’s another stick to beat us with – that we are a paternalistic, misogynist profession that has mistreated middle-aged women for decades. Following Davina’s spiritual awakening, women are calling in their droves demanding not just oestrogen, but testosterone, for a menopause that took place 10 to 15 years earlier. 

The inevitable backlash has begun, with a BMJ article in June decrying the ‘medicalisation of the menopause’, so let me be clear: I am passionate about menopause care. I have read more about this than any other subject, have completed additional training and co-produced our CCG guidelines. I am considered the menopause specialist within my practice and in my ‘spare’ time, I read case-based discussions in a specialist menopause group to keep up to date with the latest practice. 

But there are several problems with pushing for a single-issue focus within general practice. 

The first is capacity. If a physiological process is being medicalised to this extent and half the population ends up on medication requiring monitoring, what do GPs need to stop doing to release capacity for this? To steal a management phrase, the current crisis has already forced us to drop our ‘low-hanging fruit’, leaving few easy pickings in terms of freeing up more time. 

But my biggest anxiety about the vocal support for particular causes is that it invariably widens health inequalities. While I see a large increase in middle-class white women asking to be started on transdermal oestrogen and body-identical progesterone, this hasn’t filtered through to my Asian and Somali patients, who present with body pain and somatisation but have no idea why. Indeed, recent evidence shows HRT prescriptions are a third lower in the most deprived populations, with a higher tendency to prescribe oral preparations, despite increased medical risks within those cohorts. 

Finally, if the direction of travel is to create a pool of specialists and allied healthcare professionals to manage all the problems in primary care, then we’ll need to train a group of people to oversee all this and offer a holistic approach. Someone, perhaps, with a generalist background who could offer a helicopter view and manage overall risk. 

Now I wonder what we could call this person….

Dr Shaba Nabi is a GP trainer in Bristol. Read more of her blogs here