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The ‘reasonable GP’ test

Health headlines are so frequently beefed up by the tagline ‘experts claim’ that, like most readers, I have long since decided to see if the alleged experts make a word of sense before ascribing any value to their apparent wisdom. It was with some alarm, therefore, that I found myself facing the entirely novel experience of being the supposed expert myself. The article followed the Mental Health Forum where I had taken part in a panel discussion on the early diagnosis of dementia. Granted, I have written quite a bit about dementia since I started to question the current drive for early diagnosis last year; I have needed to familiarise myself with some of the literature on the subject and am starting to know what I am talking about, but I am no expert.

Indeed, the claim I was making - that the dementia DES will result in widespread misdiagnosis - is not a conclusion that requires much expertise: as one of the comments on the article states: ‘46 000 GPs could have told you this a year ago.’ What fascinates me, and worries me, is this: Why, when this is so obvious to the average GP, do the real experts - those doctors who live and breathe the field of dementia every day, the opinion leaders who have such an influence on guidelines and national policy - fail to follow the logic?

This problem is not unique to the field of dementia. GPs have had a lot to say about any number of targets and guidelines over recent years - depression screening in chronic disease, measurement of albumin-creatinine ratio in older patients with naturally ageing kidneys, sidelining home blood pressure monitoring in favour of ambulatory monitoring - all questioned by countless grassroots GPs, all imposed on us from above by supposed experts.

All too frequently there is far too much discrepancy between what key opinion leaders recommend, and what an average group of coal face GPs actually think. Why this is so, I can only speculate. Is it down to Government pressure, conflicts of interests, poor leadership, a reluctance to seem to bite the hand that feeds? I really can’t say. I suspect a major factor is that the more you specialise, the harder it is to see the whole picture. A cardiologist for instance, when making recommendations for the treatment of heart disease, is unlikely to consider the impact of their proposals on non-cardiac patients with mental health problems - an issue that might be all too obvious to the majority of GPs.

When devising guidelines and forming policy on clinical areas that impact primary care, we need to place far greater value on the voice of the non-expert, the grassroots, the day-by-day jobbing GP. Or, as Iona Heath so eloquently put it, we should Ask the Fellows Who Cut the Hay. Borrowing the title of George Ewart Evans’ masterpiece of oral history, she says: ‘It would be more than timely if those in power in this country could be persuaded to reflect on this title.’ This exhortation should be applied not only to our political leaders, but also the medical leaders who form and shape the practice of medicine through guidelines, debate and the medical literature.

One simple act could go a long way towards addressing this problem - we should apply the Reasonable GP test to any draft set of guidelines or proposals before rolling them out, asking the question: ‘would an average bunch of reasonable GPs think this was a sensible approach?’ If the answer is ‘no’ then the experts should think again. We need to encourage more GPs to get involved in this way as a sounding board - GPs with no particular specialist interest, GPs who are not trying to be consultants or experts, but who know their job, are passionate about it and actually quite good at what they do.