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?

How do GPs consult with patients?

#GPFUQ 34 How do GPs consult best with patients? The essentials are 1. Shut up and listen, 2. Care 3. Know something

#GPFUQ 35 What is the Art of GP Medicine? All of medicine minus anything that is evidence based

#GPFUQ 36 Are guidelines obligatory? No – just advice and not a guarantee of best outcome. But if you ignore good guidelines you need a good reason.

#GPFUQ 37 What's wrong with 'what’s the matter with you' medicine?  'What matters to you' medicine is more important.

#GPFUQ 38 Why do GPs need to be part of the community? In a community people know when you’re ill and they care if you die.

#GPFUQ 39 Do GPs have to be well rounded individuals? No, but they need to be part of a well rounded team.

#GPFUQ 40 Is continuity of GP care useful? The unique selling point (USP) of GP is longitudinal continuity of care that meets the needs of the patient

#GPFUQ 41 How long is a career in general practice? About 200,000 consultations. You can use them more quickly each day or more slowly over a 30 year career. You only have a finite capacity, use it well. When you have used up your supply, its time to change your job or retire

#GPFUQ 42 Are all General Practices dysfunctional? Possibly but some are much more dysfunctional than others.

#GPFUQ 43 What happens when you think it’s all going well in GP? It means that you havn’t been paying attention and havn't realised what’s gone wrong yet.

#GPFUQ 44 How do you recognise another bad idea in the NHS? The opposite idea seems just as reasonable and/or it's based on the ‘specific vagueness’ of a Govt policy.

What is GP wisdom?


#GPFUQ 25 What is real GP Knowledge? Information with experience, context, interpretation and reflection. Tacit knowledge is personal know-how, explicit knowledge is the evidence based medicine.

#GPFUQ 26  How do GPs survive complaints? Accept that it will ruin your day. Acknowledge and share the problem. All GPs make mistakes. Learn from each mistake, and avoid making the same mistake again


#GPFUQ 27 What is GP wisdom? The reward for a lifetime of listening when you really wanted to talk

#GPFUQ 28  How long does it take to become a wise GP? Less time if you know its unachievable, you just get smarter than you were yesterday because you learn from your experiences. Only the wisest and stupidest GPs never change. Mostly, you don’t discover any great truth just recognise your mistakes more. The more mistakes you have made the wiser you may be! To become old and wise you usually have to learn from being young and stupid. The opposite of wisdom is making the same mistake over and over.

#GPFUQ 29  What the difference between experience and making mistakes. Experience reminds you and makes you recognise a mistake when you make it again. Its inevitable that you will make mistakes – that fuels learning. It you keep making the same mistake – that’s incompetence.

#GPFUQ 30 Why do smart people do stupid things? We are overwhelmed by an illusion that influences our thinking and makes the nearest and easiest solutions seem the biggest and best options. This is known as ‘the hyperbolic discount curve’. We may be trying to make decisions without sufficient information, when we are distracted, or based on flawed assumptions. We need our wisdom to lash us to the mast and let us override impulses and compelling illusions and direct a different way of thinking and action based on life experience, self awareness, patience and choice. With increasing experience wisdom gradually governs our willpower. See also #GPFUQ 33

#GPFUQ 31 Can wisdom be taught? There is a faster way to be wise. Wisdom is way of travel rather a destination. Its always influenced by your age and experience. Asking the question – is this a wise choice is a good start.

#GPFUQ 32  What's the personal difference between success and failure? Success gives you a habit, failure gives you learning

#GPFUQ 33 What is gut reaction? That personal special sense that warns you that something isn’t right. This is really expert intuition – its nothing more than recognition of patterns. You may not be aware that you have recognized a pattern or something that doesn’t fit in the expected pattern but the mind processes more quickly than we can comprehend and if you’re aware of it you are alert to its warnings. There is a danger when you leap to conclusions that you have insufficient information to recognise a pattern but are influenced by something similar you have just seen..this creates the 'strong but wrong' gut reaction.

Whats the difference between change and improvement in general practice?

#GPFUQ 17 Why does so much change in NHS cause worse care? It creates a constant struggle against difficulties which would not exist without the change.

#GPFUQ 18 Whats the difference between change and improvement in general practice? Quality. If you want to improve, not just makes changes you must ask and answer the basic quality questions before you plan any change.

This is  ‘continuous quality improvement’. The five basic questions you need to ask (and answer) when you try to improve something are: 

1.            What are you trying to achieve?

2.            What do you currently know about the subject?

3.            How will you know if you have been successful? i.e What are the success criteria?

4.            What can you actually do (with the resources you've got) ?

5.            How and when will you continue this cycle of action, question and feedback?

#GPFUQ 19 What do you need in a good health service? Easy access, low cost and high quality

#GPFUQ 20  What should GPs trying to achieve?  Make your organisation provide higher quality at lower cost and make the practice systems better and easier to use. 

#GPFUQ 21 Who achieves high quality GP? The best practices usually have a mix of one or more of three cultures.  

1. The enthusiasts are the early adopters of new ways to practice. They are technophiles. There is usually a GP who looks for high quality care and efficiency. These enthusiasts find new ways to practice and often speak in terms of the time it takes to get something done. They are innovators and can change practice quickly and easily and stimulate practice wide improvement as change champions. 

2. The motivators put extra effort into motivating and enabling staff to play important roles in improvement efforts. Strategies include a GP promoting importance of new activities in conversations and behaviour, meetings to check feedback, progress and make plans, work with practice staff to select indicators for improvement and designed activities to achieve improvement, and quarterly half day meetings when the practice was closed dedicated to making improvements. These practices have more mixed feelings about software than the technophiles. 

3. Lastly there are the businessmen – practices take a business approach shaped by customer services and risk management. They organize special service in the form of focused management clinics, hiring staff as needed. Problem-focused clinics (e.g. diabetes, hypertension) are designed to provide comprehensive, competitive, guideline-adherent care convenient for the patient and ensure that the doctor has done everything possible to manage care. Lead doctors delegate care management responsibilities to staff and provide regular supervision, such as weekly care coordination meetings between nurses and doctors. They redesign delivery systems to support the special services. They conduct point of care tests and use in house lab so that test are available for the patient when they attend. 

A mix of all three works best.

#GPFUQ 22  Why do we need bad GPs? Look around if you can’t see any bad GPs maybe its you.

See also https://www.bmj.com/content/370/bmj.m3415/rr-2

#GPFUQ 23 How to make quality GP?  Improve all the time, define the problems, challenge others, share knowledge, respect others opinions.

These are the Toyota principles for creating  a high quality organisation? The culture needed promotes the organisation to:

Improve all the time; improvement is a continuous process, it's never complete. 
Define the problem rather than produce solutions; go to the source or find the facts. 
Challenge others; problems create the need to improve. 
Share knowledge; teamwork makes improvement more efficient and effective 
Respect other opinions; if two people always agree, one of them is superfluous.

#GPFUQ 24 Whats the reality of quality improvement? Constant effort with occasional success and frequent failure. 

Andrew Perrin summed up the reality of quality improvement when he was quoted in the New York Times talking about how his University planned to reverse grade inflation and make grades more meaningful.  ‘Its going to be modest and nowhere near enough to correct the problems, but its our judgment that it’s the best we can do now’.