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

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