How much or how little should a GP do?

#GPFUQ 71 Are you a broad or a narrow generalist? 

Narrowists do very little and must refer everything for someone else to do later.

Broadists try to do everything needed now themselves.

A generation ago – a GP was an unrestricted broad generalist and could do most things. Skills were learnt on the ‘see one, do one, teach one, then delegate one’ model. Over the course of a 30 year career there is a shift in the skills that a GP wants and need to provide in normal working practice. At the beginning of a career a doctor may be eager to learn to do a procedure, at the end of a career the same doctor may have delegated the procedure to another member of the team. At times a GP might still need to be able to ‘do one’. In the same practices different GPs would be at different stages of the ‘see one, do one, teach one, and delegate’ model’.

Some GPs would always be narrowists and opt out of doing things. What a doctor can do and or is prepared to do depends on the doctor him/herself (e.g. knowledge, skills and attitudes), the patients characteristics (e.g. urgency of condition, expectations, personality), the practice culture (e.g. whether its more self serving or customer serving) its resources (e.g. the support available in the practice), the bureaucracy set by local and national NHS (e.g. the remuneration processes at work, statutory obligations), the current fashion or evidence for care, any formal accreditation of competencies, the prevailing culture for risk management, and the particular circumstances specific to a given day (e.g. what else is happening that day). The sum of all the current influences seems to creating more narrowist GPs. Everything must be referred to someone else for action. How can this trend that may create GPs who can’t do much for their patients be reversed?

Good patient experience comes if the GP has and uses a breadth and depth of knowledge and skills and there is good communication with, dignity and respect for, and involvement in decisions with the patient. Each GP has to stop and think about what is shaping his/her performance and be able to defend his/her actions as ‘the best option available for the patient at that particular time’. Each GP should do whatever needs to be done him/herself now and challenge any blocks to being a broad generalist .

#GPFUQ 72  Should GPs provide only basic or extra services?

If GPs don’t do the work – will GPs become deskilled? There are contrasting views about what GPs should be able and prepared to do. The basic skill set for some GPs is considered extended roles by other GPs. Many patients, and practices want GPs who provide more than the basic care, and many GPs want to develop or maintain special expertise. Most money is spent on secondary care, and a higher percentage of the little spent on primary is still not much, so it makes sense to invest more in primary care especially if it can reduce the costs of secondary care. However opinions seem divided about whether GPs should routinely provide extended services. Some GP want to stop trying to provide services such as pre op and post op care, counselling patients, advising re smoking, and other lifestyle advice - diet, exercise, cholesterol etc, dealing with stress and mild depression, and any secondary care work delegated to GPs. Other GPs want to take on more services such as more active involvement in antenatal and maternity care, identify and proactively contact their patients with Learning Disabilities, adolescent medicine, ultrasound scans, palliative care, more minor surgery, extended consultations in mental health, Mirena insertions, male screening, open healthy cafes, hosting weight loss boot camps.

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Suggestions for action

• Each year identify what services are needed locally, which are the priority for that year, and collaborate with others to provide these services
• Each year identify what skills each GPs or staff member wants to develop or continue for their own professional development and satisfaction and try to provide a development plan and opportunity
• Make a business case for any GP specialist services and seek appropriate funding
• Delegate as much as possible by acting as a communication "hub" to provide services e.g. make community matrons be utilised as much as possible
• Sort patients together to provide a scheduled group based solution eg group diabetes education session, group stop smoking sessions

Why must GPs reduce the paperwork?

#GPFUQ 70 Why must GPs reduce the burden of paperwork? It increases the barriers to good care.

The paperwork in paperless offices is worse than ever. The burden of administrative tasks keeps increasing. This can make life harder for patients by erecting barriers to protect GPs from this increasing administration work. If GPs don’t do the work – will patients have to work harder or make more or different appointments with many different staff for different services? It won’t be a good service for patients (or a good marketing strategy for GPs) if a GP who has traditionally provided an accessible  ‘one stop shop’, increases the barriers to care, reduces accessibility to or reduces range of services on offer for patient.

Some suggestions for action

• Keep a clean / clear desk policy. If you can’t do this then get advise on what you have to do to achieve this.
• Reduce the time spent on practice management as much as possible - recruit a well-qualified manager as employee or business partner to manage the partnership and practice business
• Don’t write a letter to a patient if a phone call or text would be quicker
• Delegate all administration (see FUQ 60-62) to your staff
• Appoint a clerk to run processes like the Choose and book appointment system
• Use wholly computerised records – don’t run duplicate systems on paper and computer
• Use  forms in ‘Word’ and present in a way that allows merging with GP clinical systems
• Reduce your paid and unpaid subscriptions to societies, magazines and mailings to a minimum
• Throw away most journals, unfocussed reading, etc
• Unsubscribe from unwanted / less important e-mail systems
• Don’t respond to unsolicited questionnaires
• Use READ codes more to record clinical information
• Pick the important information and actions required from incoming letters, and routine investigations results to alert you if need to do something
• Don’t attend administrative or representative meetings unless your presence will directly contribute to the outcome of the meeting.
• Don’t attend unnecessary training e.g. how to give a flu vaccine when you are giving injections all the time
• Don’t do any low-end clinical work (vaccinations etc.) that could be transferred to other staff.
• Ensure office staff have month by month tickler files that remind them to routinely repeat searches, e.g. patients on warfarin without an INR for 3 months
• Designate a Duty administrator i.e. someone each half day that can do all those jobs like... chasing appointments, finding consultants secretaries, relaying messages etc
• Use the administrative team to prepare medical certificates, insurance reports etc
• Use the administrative team to contact patients (a medical assistant can do this)
• Use the administrative team to chase hospital system
• Use the administrative team to chase social care support (social services and community matron can lead this)
• Use the administrative team to monitor chronic disease and make adjustments to standard drug regimes
• Don’t participate in any process work and planning meetings without specific goals
• Don’t participate in any audits for their own sake, only those to improve patient care
• Use annual or birthday based medical reviews of all chronic diseases at one visit per year
• Have Practice protocols for consistency of approach - e.g. patients arriving late, dealing with housing letter requests, etc
• Use internal electronic messaging or have a paper system on trolley outside consulting room (in a practice where patients are waiting away from this corridor). Sort into different shelves - routine hospital letters/ probable junk and magazines/ urgent requests inc urgent prescriptions and messages from consultants, etc. This can be helpful for reception team who  would know that the urgent basket would be looked at as morning went on and didn't therefore disturb the doctor,
• Use the administrative team to provide up to date database of contact telephone numbers, service provisions et- kept up to date and accessible to locums as well as regular doctors.
• Use the administrative team to provide up to date standard locum packs such as that provided by National Association of sessional GPs (NASGPs)
• Use the administrative team to facilitate Patient Participation Groups
• Use the administrative team to facilitate Patient Therapy Groups
• Have excellent full team away days. There should be funding and support for one every year.
• Lobby RCGP and GPC to help end unnecessary structures and processes in general practice faster – there is a legacy of unnecessary chores that GPs do that we need to collaborate about to change e.g. many sick notes for patients add nothing to the care or management of the patient. RCGP or similar needs to take a lead in ‘best practice’.
• Maintain up to date disease registers in the practice
• Share work with multidisciplinary teams when appropriate
• Concentrate on the  complex medical decision-making that is often done face to face.
• Don’t collude by allowing reception staff to triage patients, due to a lack of clinical staff time.
• Have ring-fenced time for vital non-consultation tasks.
• Protect learning time for leaders in practice

Please send me your suggestions to add to this list