What should GPs do for their patients?

#GPFUQ  89 What should GPs do for their patients? You should never do for others, what they can do for themselves. 

#GPFUQ 90 How can todays GPs survive a 40 year career

Not Waving but Drowning. Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
 And not waving but drowning.

Poor chap, he always loved larking
And now he's dead
It must have been too cold for him his heart gave way,
They said.

Oh, no no no, it was too cold always
(Still the dead one lay moaning)
I was much too far out all my life And not waving but drowning. Stevie Smith

Every career in general practice changes.How can any GP hope to survive a 40 year career with increased  demand, for care, extra expectations of GP expertise, more external regulation of quality, against a background of difficult changes and austerity. GPs need to develop an informed plan for a long, progressive and mostly enjoyable career in general practice..

All the world's a stage, And all the men and women merely players; They have their exits and their entrances, And one man in his time plays many parts etc . Shakespeare

#GPFUQ 91 Whats a GP personal development plan? Identify what you want to achieve and your learning or development needs, prioritise them, match those needs with opportunities to learn, check it worked. GPs need to do this as part of NHS appraisal. The most important parts of a PDP are not what you what are going to do in the next 12 months anyway, it’s the longer term planning you need for a 30-40 year career. You may not be able to think in terms of 30-40 years but you can make a plan with milestones for the next 5-10 years. You can make changes to your plan as you progress in your career and as opportunities arise.

#GPFUQ 92 How can GPs manage the demands of  the ‘Get a note from your doctor’ culture GANFYD,

This includes sick certificates (or fit notes) for employment, social control certificates for school and housing issues, sick notes for students and school children (so they don't lose their bursary for one day), certifying long term sickness absence without knowing any of the workplace adjustments achievable, filling in review forms for multidisciplinary panel meetings, dealing with some agencies problems / agendas regarding shedding responsibilities for care – e.g. the home care is concerned but the relatives are absent, completing paperwork for other government agencies, and housing forms

Suggestions for action

·               Have a rubber stamp made or automatic letter – e.g. I am unable to answer this request for a ‘note from your doctor’ in a meaningful or informative way

·               Provide instruction and facilities for patients to self write sick notes or other notes and ask patient to complete the sick or fit note ready for signing by their GP. In many of these circumstances there are no objective symptoms and signs of illness for a GP to document or certify, a doctor has to rely on the patients report of how they feel or felt. Whenever possible the patient should complete the text of the relevant certificate and a doctor can sign the certificate to attest the reasonableness of the text. No appointment to see the doctor would usually be necessary, or a telephone or email consultation might be sufficient.

·               Always charge a fee for certificates that are not part of NHS GP work.

#GPFUQ 93 Why is it sometimes important for a GP to pretend to have the memory of a goldfish? So as not to get upset over a long career when the endless circle of changes  brings back old ways of working as new bright ideas again and again.

#GPFUQ 94 Consultations – How difficult is it for GPs to schedule more efficient and effective patient consultations ‘how to get better time for consulting with patients’

Patients will always want time to discuss their problems. The appointments system (including face to face, telephone and e-mail consultations) must meet their expectations. The best appointment processes seem to manage the first contact with patient better, avoiding any user-unfriendly barriers, allow the patient to get through to someone who knows them, and provide open access scheduling so that everyone who wants an appointment that day will be seen that day. GPs should use telephone consultations more and structured e-consultation to make the process more efficient and effective and ‘stopping the ping pong of emails and with patients’.

Practices who triage all calls seem to manage their workload better ‘telephone triage of same day requests works well (done by GP's with personal lists)’ ‘our telephone triage service saves time’

Suggestions for action

·               You must know how many appointment you really need and always have enough appointments to meet demand – ‘it reduces stress for patient and staff’.

·               The appointment booking systems must have enough capacity both in terms of the number and types of appointments and be easy to use. This will ‘reduce the amount of time spent coping directly or indirectly with the consequences of poor systems’.  You may need to change appointment system to reflect the local demographics.

·               If you can’t provide enough appointments to meet demand, you must change your way of working eg more triage, more telephone and e-consultations, more delegation and skill mixing.

·               Have a health professional sift the booked appointments in advance and plan what else needs to be done before or at the appointment eg pre-consultation checks (BP, weight, urine) by a Health care assistant. Clinical prompts and pop ups on the GP computer system do the same as long as they work.

·               Protect routine work from the demands of urgent work. Provide a dedicated duty doctor +/- nurse practitioner: this protects others clinicians from fluctuating and urgent demands. They also have time to deal with patients more thoroughly and appropriately, rather than rushing urgent work alongside routine clinics

·               Have fewer face to face consultations, more phone and email consultations if medically appropriate

·               Provide a mix of appointment times - short/medium/long

·               Provide longer appointments. 10-12 minute appointments may be the current standard appointments but 15-20 minute appointments seem needed so that fewer patients are more thoroughly reviewed with as many problems as possible dealt with in each consultation ‘you can get done in 15 minutes almost as much as in 2 x10 minute appointments and the patient doesn't have to take 2 half days off work and you don't spend several minutes each consultation saying hello, goodbye and trying to remember what was going on’. ‘Longer appointment times might allow more problems to be fully resolved in one visit’.

·               Vulnerable people eg learning disabilities and patients with complex need more time - target them for 20min appointments.

·               Arrange for multiple chronic pathology patients to be seen for half-1hr appointments once or twice a year for co-coordinated management planning.

·               Have telephone triage of same day appointment requests

·               Follow up of patients with phone calls rather than repeat appointments

·               Provide Online booking

·               Use SMS text to communicate with patients

·               E-consultations - The best process seems to provide a structured email consultation route ie one that patient can access via a web page but ensure that patient uses a structured process in the consultation. This avoids patient writing a letter and clinician having to ping pong emails backwards and forwards - see HHC example xx

·               The RCGP should publish a template for best practice

#GPFUQ 95 when does a GP need to do a visit to a home or residential care home? Some patients do need a home visit. But compared to face to face consultation in the practice, home visiting limits the resources available to the GP, and can also be a less efficient use of a GPs time so has to be managed effectively. Is a GP visit adding value, or would some other action be better?

Suggestions for Actions

·               Identify the truly housebound patients, and make sure their status is clearly visible in the electronic health record

·               Set up alternative transport arrangements for patients who could be seen in the practice e.g. set up a patient volunteer transport service, make an arrangement with a local taxi firm

·               Try to have personal lists or one doctor for the practice per care home

·               Have nurses visit the housebound and residential care homes

·               Provide a weekly "ward round" visit to a local nursing home to provide better care of all the patients and decrease unnecessary acute admissions to hospital.

·               Have regular pre-emptive meetings to discuss the best care of the housebound and residential care homes

·               Avoid pastoral home visits, routine and repeat home visits

#GPFUQ 96  What is NHS idle chatter?  We should be discussing the ideas and ways for improving the NHS, not the events,  nor the people who run the NHS.

Do GPs need to have a certificate of competence in everything they do?

#GPFUQ 81 Do GPs need to have a certificate of competence in everything they do? No – GMC accreditation means that you are certificated as competent to know if you need a certificate of competence in anything extra

#GPFUQ 82 How much retraining do GPs need to do to keep them competent in procedures? Is obligatory re-training needed or are we re-teaching grandmothers to suck eggs? A bureaucracy of training and accreditation has developed that is not linked with personal learning needs or effective learning e.g. how many cervical smears or IUCD coil fits do you really need to do each year to remain competent?  Training should be directly linked to an assessment of your learning needs and produce effective learning. We should stop obligatory retraining on things we remain competent at and keep it for those things we may not be competent in because we don't do very often but do need to know. The RCGP should research, and give continually improving guidance on best practice on accreditation and reaccredidation of procedural medicine.

#GPFUQ 83 Why are there so many part-time and non-partner GPs giving full time and GP partners advice? There is a new career choice in GP – the non-practicing GP. This is someone who is not a partner in a practice, and does not do more than 2 days of clinical work each week as a GP. In the past  it was difficult for GPs to get paid for not working as a GP. There were a few academic GPs who were usually benign but also lacked any power. The new non-practicing GP career choice is to be an uber GP either as an academic, a manager, educator or appraiser GP. Most remain benign but some of these non-practicing uber GPs seem bureaucrats who set difficult standards for others to attain and may have little tolerance for contrary ideas or opinions (see #GPFUQ 84).

#GPFUQ 84 What is dogmatic General Practice? One where the GPs increase their effort after they lose sight of the goal or can't change their mind. The dogmatic GP displays selected strict standards and little tolerance for contrary ideas or opinions.

#GPFUQ 85 What s the difference between your GP vision and your GP mission. A mission statement gives your purpose, basically why your GP service exists, what it does and for whom. It’s a guide that spells out what your organisation is all about. The mission should focus on the here and now. A vision statement outlines the goals and aspirations for the future. It’s a mental picture of a specific target and should be as a source of inspiration

#GPFUQ 86 How do you become a GP leader? It’s easiest if you are surrounded by followers. It also helps if they want to follow you. They are more likely to follow you if you have charisma, power or money. None of these will make you an effective leader. If you don’t have charisma power or money then you have to build a history of success in what you do.

 I was in a group of Britons having political lectures at an election time in the US. We were outraged because it seemed that the candidates needed millions of dollars to have any chance of success. The Americans dismissed our cynicism with ‘what sort of leader would he/she be if he/she couldn’t raise a million dollars?’

As a leader you become responsible for producing the culture (what we do) and climate (how it feels). If you are a good leader you can increase your followers willingness to make extra efforts (their free and discretionary effort) for you. The main types of leadership are: Coercive – do as I say, Visionary – come with me, Affiliative - People come first, Democratic - what do you think, Pacesetting - do as I do now, Coaching - Try this. The least effective for most situations are the coercive and pacesetting though these may be essential in emergency situations

#GPFUQ 87 What sort of GP team do you need? The team that allows you be the best sort of doctor you want to be. All teams have a weakest link. Removing the weakest link may just move the problem to the next weakest link. You need to decide just how strong each link must be and stick to that standard.

#GPFUQ 88 Why don’t care pathways and plans seem to help improve care.

More extended teams cause more complications with communications. Responsibility for patients and liaising with others becomes a problem. The care of many patients with complex conditions or co morbidities involves many people. In general practice all staff accessing and using the same electronic health record makes care more efficient ‘everyone knows what everyone else is doing’ and the care is usually coordinated by one member of the team. A more formal multidisciplinary approach is needed.

Suggestions for action

·               Multidisciplinary team (MDT) working – institute regular review of problematic patients with MDT.

·               Introduce case management, selecting case by case the best profession for the particular patient. For a minority the GP will be / remain case manager; for the majority it will be other professions.

·               Use fax/email in a timely manner so that MDT meetings with other healthcare workers can be used well and avoid the whole team listening to "detail" or "catching up" about specific cases rather than real learning points or improving service

·               Inform patient and the MDT of MDT care plans

·               Engage experienced nurses to do more case management.

·               Integrate care managers work near the patient  – don’t let them do care management from a distant office

·               Make sure there is a designated social worker attached to the practice to improve collaboration with the social services to increase quality for patients

·               Redesign clinical pathways with secondary care colleagues to make the simplest possible pathway for patients

·               Review management of patients who get their "care" from hospital services, and institute case management in primary care

·               Increase the use of voluntary groups e.g. Parkinson's society

·               Have some effective method to hand over information from the practice to Out of Hours care and vice versa.

What's the second rule of three in general practice?

#GPFUQ 73 What’s the GP-patient communication formula? Effective communication with a patient is proportional to your understanding and respect of that patient.

#GPFUQ 74  What’s the formula for a patient following a recommended treatment? A patient’s adherence to a recommended treatment is equal to the patient’s preference plus the treatment’s relevance multiplied by its perceived effectiveness divided by the sum of the effort required to adher and the adverse side effects

#GPFUQ 75  What’s the 4+2 formula for successful GP management. The GP management includes the four essentials - good strategy, execution, culture and structure plus at least two of the secondary management practices- good talent, innovation, leadership and partnerships.

#GPFUQ 76 What’s the formula  for living with bureaucracy? If a problem is impossible to solve, you have to handle it where it lies.

Any large organization has arcane practices that need to be challenged. The NHS and the rest of the bureaucracy asks us for lots of meaningless information, and often refuses to process our requests unless all the information is supplied. Much of the requested information is of no practical use other than to establish who we are, what we say we’ve done, and that we are compliant. The aim is to reduce the  micromanagement of work that results in more time spent on  paperwork and less time for clinical work. It's best to work with the NHS and others to reduce unnecessary bureaucracy. Agree a ‘can do’, ‘no blame’, ‘have patience’ approach to improvement and stopping requests for unnecessary information. Always question non-evidence based work e.g. work related to unvalued target chasing

#GPFUQ 77   What’s the first rule of three in general practice? A patient (and the GP) are only likely to remember three things from any consultation. Decide what are the most important three things to remember in each consultation.

#GPFUQ 78  What's the second rule of three (or the three strikes rule) in general practice? If a patient returns three times with the same problem and you haven’t been able to solve it then you should refer the patient to someone else to help solve the problem e.g. refer to a specialist.  

#GPFUQ 79  What's the third rule of three  in general practice? Heaven in general practice is 3 patients in a row one with diabetes, one with depression one with asthma. Hell is 3 patients in a row with the same problem depression, or diabetes or asthma 

#GPFUQ 80 How long is the attention span of a GP? It varies throughout a career. It may start at about 20-30min but after a  lifetime of dealing with problems in 10-15 minutes slots  it becomes about 10-15 minutes. 

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

Can GPs do everything?

#GPFUQ 53 Can GPs do everything?  Anything is possible if you don’t have to do it all yourself.

#GPFUQ 54   How can GPs manage time better? All GPs say there is ‘not enough time’. Most can find the time to do the things they really want to do. But that leaves all the rest. You don’t really want more time to do these, you want less of them. The usual causes of time wasting are poor planning, procrastination and personal disorganization. You use time best when you are committed, know what you need to do, own the work, and can work in small steps.

#GPFUQ 55   How do you plan your GP days? Do you spend too much time on urgent tasks and neglect the more important but less urgent. You have to recognize the four types of demands on your time: What is important/urgent, important/not urgent, not important/urgent, not important/not urgent. Make your prioritized action list and delegate or dump all the non important demands.

#GPFUQ 56   How do GPs improve their planning? Know what you are trying to do and prioritise your efforts. This makes you use your time better and can make your work and life more satisfying. Does you current work and life goals match your current activities? Where are you now? Do you spend your time meeting your priorities or other people's? Identify any time wasting activities that contribute very little to your goals? Are you making your life and work easier and better or something else?

#GPFUQ 57   How do you prioritise? Review your work and life goals. Where do you want to be? How will you get there? Organise your time into priorities that match your work and life goals. Your activities should contribute to these priorities.

#GPFUQ 58   Are you assertive enough? Managing your time includes saying NO to people who impose their priorities on you. You can't do everything so you must refuse or delegate whenever possible.

#GPFUQ 59   How do you make an Action or Smart List? If it’s not written down then it’s just a wish list. ACTION lists are A-Are measurable 
C-Compatible 
T-Time specific 
I-In Writing 
O-Owned 
N-Negotiated or are SMART lists S-Specific M-Measurable 
A-Attainable and achieveable 
R-Resourced and realistic 
T- Timely

 #GPFUQ 60   What should you delegate? Anything recurring; anything someone else can do better; minor decisions; or when it involves time consuming details

#GPFUQ 61    When should you delegate a job? Nothing is impossible as long as you don’t have to do it yourself. You should delegate when no one else but the person selected  can do the job; the job is very technical; its more cost effective for someone else to do; there is an opportunity for employee development

#GPFUQ 62    How do you delegate? Give clear instructions; give the authority; give adequate resources; build in accountability; reward success

#GPFUQ 63   How do you do ‘project management’? The essentials get dressed up in different project management jargon, but are

1.             A clear, shared understanding of the desired outcomes (Aim and Vision and Objectives)

2.             A clear plan detailing what they are going to do (milestones and deliverables)

3.             A clear understanding of the barriers that will and may come up (The risks)

4.             A plan to mitigate these risks

5.             A clear understanding of the resources needed to deliver the plan (the business case)

6.             A clear agreement and understanding of who does what (roles and responsibilities)

7.             A simple method for monitoring progress and success (performance management and evaluation)

#GPFUQ 64   Can you improve your personal organization. Ask ‘What am I doing and why am I doing it’. Know how you do spend your time. Identify your best times for working. Try planning tomorrow today.

#GPFUQ 65    Can you reduce your procrastination? Just get started, accept that you are delaying because you don’t want to do it, be honest with yourself that you are no more likely to want to do it later

#GPFUQ 66 Can you manage paperwork better? Handle each piece of paper only once. Work from an action list with your priorities. Save time on email/letters by processing incoming mail at the same time each day. Handle each piece of mail only once. Do it, delegate or dump it. Write your reply on the incoming letter. Keep it brief, Get to the point, Don’t procrastinate, Be accurate, Use the proper etiquette. Don’t respond in writing if a conversation, phone call or something else can do the job. Focus on 1 or 2 tasks at a time.

#GPFUQ 67  Can you manage interruptions better? There are three types: necessary, necessary but untimely, or unnecessary. If you are interrupted ask or say something like ‘What can I do for you?’ Followed by ‘is there anything else?’ Then establish the priorities and ask  ‘How long will it take?’ Check ‘Do you really mean a few minutes?’ Or suggest ‘I’m right in the middle of something right now, can I get back to you at 2pm?’ It’s easier to control your time if you visit others to talk, you can leave when you want. Other ploys are announce a time limit. ‘I can give you 5 minutes’; schedule regular meetings if you are frequently interrupted; talk whilst you are walking somewhere else; get to the point; hang a sign on your door; keep your door shut

#GPFUQ 68   Are you disciplined? If you start your day with a written ‘To Do’ list, you can try and work to a daily timetable and target goals that have to be achieved by a certain time each day. If you can do it, do it now, don't wait until tomorrow.

#GPFUQ 69   Are you disorganised? To avoid wasting time looking for misplaced items, keep records and use of diaries, filing and reference systems. Different systems suit different people but some system is better than no system.

How do you get a reputation as a good GP?

#GPFUQ 45   How do you get a reputation as a good GP? You don’t get one by saying what you are going to do. 

#GPFUQ 46 How do GPs learn & improve? Keep asking questions (and get the answers).

#GPFUQ 47 How do GPs learn best?  They get solutions to their problems, can ask questions and don’t have their time wasted

#GPFUQ 48 What are the important questions when you plan a change in GP?  1/5 What are you trying to achieve? 2/5 What do you know or need to know about this subject to plan change? 3/5 How will you know if the proposed change is an improvement i.e. what are the success criteria? 4/5 What changes can you make (with the available resources)? 5/5 How will you continue the improvement in a cycle of feedback and change?

#GPFUQ 49 How should GPs teach others? Ask 1/6 What do you need to know? 2/6 What do think is going on with patient? 3/6 What’s your underlying reasoning then 4/6 Give positive feedback 5/6 Teach any general rule 6/6 Correct any errors.

#GPFUQ 50 How do you encourage new ideas in GP? Ask how would it work? Who would need it? How could we do it?  Then listen and build on the idea.

#GPFUQ 51 How to chair a GP meeting in five steps? 1/5 There are 4 basic rules: courtesy and justice to all, consider one item at a time, minority must be heard but majority must prevail. 2/5 Items on the agenda should be either for information or for action. Action items dictate an outcome either approved, denied or tabled until the next meeting 3/5 Chair must stimulate discussion and participation but keep the meeting focussed on the agenda 4/5 Chair firmly deals with any emerging items. Emerging items can be ‘parked’ as the meeting is conducted until the end of the meeting, then dealt with if there is time, or be new business on the agenda of the next meeting. 5/5 Chair asks committee members once a year 1. Did everyone have a chance to speak 2. Did you have a chance to speak 3 Were decisions on the action items achieved 4 Were information items useful 5 Was business accomplished in minimal amount of time 6 were emerging issues dealt with effectively

#GPFUQ 52  Who is in charge of GP?  There are no ‘they’ who are responsible only people with names. If you can find the named person in charge then you can ask: Who gave you this power? How did you get this power? What will you do with this power? Who are you giving your power to? How can we get rid of you?