Why is there a crisis in GP numbers?

#GPFUQ 149 What’s the big crisis in GP numbers? The recruitment problem is that not enough junior doctors want to train in general practice and not enough want to train in the under-doctored parts of the UK. The retirement problem is that too many GPs are aged over 50 and too many are deciding either to retire early or not continue working after the age of 60. The retention problem is in response to the changes in work that too many GPs are quitting careers in general practice too early.  The returner problem is that GPs who leave UK practice for more than 2 years but want to return have to have a period of low paid retraining. The regulation problem is that the bureaucracy of payments processes like the Quality Outcome Framework, and accreditation processes like the Care Quality Commission make GP work unpopular. It's clear that we have to challenge and change current recruitment, retention, retirement, returner and regulation practices if we want the NHS to continue with the primary care registered list that provides care for all patients and protects the secondary care from too many referred patients.

#GPFUQ 150 Why is there a crisis in GP numbers? The accumulation of past errors and current circumstances has created a perfect storm! These probably include the structural and process problems that allow the largest UK specialty (General Practice) to be relatively under-represented in all the organisations that influence the choice of medical careers; the rapid expansion in numbers of hospital specialists (possibly at the expense of general practice) with more sub-specialists who need more junior doctors to, the relative underfunding of primary care (compared to secondary care) at a time when workload is increasing, all the other portfolio jobs that can divert GPs away from clinical practice, the changes in GP workforce that necessitates more parental leave and more part-time working, the reduced pension cap that means many older GPs reduce how much they work to match their pension cap,  the burden of over regulation with revalidation and Care Quality Commission, the weekly onslaught of bad news about general practice in the media and the increasing demands that mean a GP’s day is often a busy 11-12 hour day.

#GPFUQ 151 How do you solve the crisis in GP recruitment? Hold the feet of the politicians, civil servants and medical speciality leaders to the fire on consequences of a NHS without effective primary care. Ensure each and everyone responsible is held accountable for their actions and inactions. Some suggestions include placing more medical students and Foundation doctors in the practices where they are most likely to be inspired to become GPs. Its not surprising that if medical students and Foundation doctors spend most of their time in hospitals, and have straight forward career paths in hospital they may be biased towards a career in hospital medicine. The status quo has failed to provide the balanced workforce we need.  A better way may be for medical students, Foundation doctors and GP trainees to spend at least 50% of their time in general practice learning medicine by following patients who have the specific health problems listed in their medical curriculum on their journeys though the health and social care services.  We must also promote Foundation and GP training in the under doctored areas otherwise the NHS will collapse in those areas. The NHS and Health Education England must use all the carrots and sticks at their disposal to get junior doctors working in the right numbers in the right specialities in the right areas.

Why do GPs use IT like its ‘paper under glass’?

#GPFUQ 146  How do you get big projects started and finished? 

This is the how do you herd cats question. First recognise and work on all the different elements; the political dimension, the personal dimension, human behaviour, organisational behaviour, other interests, motivations and blockers, the time and timing. Second make a start (it’s the essential first step), work at it (it won’t happen by accident), accept steady progress (it will take time to deliver), try to create independent brokerage (avoid any conflicts of interests), recognise any vested interests (pander to them when necessary), encourage friendship (like each other and be happy), bring dissenters inside the tent (use their ideas and energy), deal with key stakeholders individually (formally and informally and be flexible with your approach), be trustworthy, honest and open (but leave some room for secret manoeuvres).

#GPFUQ 147   What’s the secret of life?  

Honesty and fair dealing. If you can fake that, you've got it made.  Groucho Marx

#GPFUQ 148 Why do GPs use IT like its ‘paper under glass’?

Practices have been paperless for years but often they use the new technology to work in the old ways - the ‘paper under glass’ mistake. Practices fail to use IT to its full extent.

Some suggestions for action

·      Ensure consistent use of practice computer system by the practice team. This does require training and expense - but makes notes much more useable

·      Have regular sessions to share ‘top tips’ on how to use IT in the practice.

·      Find out and use all the shortcuts like macros on your computer system

·      Stop duplication of any work that’s on paper and computer

·      Have all the forms and letters you use formatted as mail merge so they are automatically filled by the computer

·      Build synchronized actionable alerts (i.e. they routinely prompt at the right time what’s needed for good long term care) in the EHR, and train the team exactly when to act on them in their daily routine.

·      Make sure that when you design something it fails safely. For instance don't send out emails saying "get back to me if there is a problem on this"

·      Gets patients to enter more information in the EHR - home BP, Glucoses, questionnaires

·      Use non-clinical portions of EHR templates to record other important information e.g. contact details for next of kin, key worker for mental health patients so that any clinician can find this information easily

·      Use internet technology that facilitates new ways of communication mechanisms e.g email consultations with patients, use web cam link from patients home to surgery, videoconferencing, facebook, twitter, shared documents etc

·      Automate data extracts and collection – e.g. on referrals, workload. Data drives improvement.

·      Use e-mail to ask clinical questions and to liaise with and get support from secondary care

·      Use email distribution lists, always use a subscribe and unsubscribe option

·      Use Youtube to spread learning e.g. instructions for patients on self management

·      Avoid looking at the screen instead of looking at the person - this is a false economy in terms of time, people need to feel listened to

·      Use Voice recognition software instead of typing to enter clinical notes and write letters

·      Get joined up with the other relevant health and social care IT systems. Liaise with third parties like Hospital Trusts to ensure GPs can access hospital IT systems from their desktop PC. E.g. access pathology reports

·      Insist on having ‘single signs on’ to access the various other systems you need to use on your computer. Single signs on will increase their use.

·      Integrate referral pathways from third sector partners

·      Use decision support tools that help you provide informed consent e.g. What are the numbers needed to treat for the intervention you are recommending

·      Make sure information does not need to be entered more than once

·      Allow patients access to a copy of their personal health record and gets them to check that its correct

Should GPs use their professional judgement or follow guidelines?

#GPFUQ 143 Should GPs use their professional judgement or follow guidelines? Is it more important to follow a pre determined performance pathway (like guidelines or payments for performance) that links all aspects of work (e.g. effort, achievement, values, purpose, and self understanding) to measures and comparisons of output? Professional judgement like any practical wisdom is a form of knowledge that is not formally taught and learnt but is acquired mostly through experience and informal conversations. Wisdom develops through continuing critical deliberation about what is the best thing to do in practice. This is more than learning from simple reflection. In general practice it is the use of a clinicians professional judgement that should help individuals manage the uncertainties and risk in their lives.  A modern paradox is that GPs are trained to use their judgement for the best interests of their patients but all the prescriptive legislation and guidelines doesn’t allow them to use their judgement anymore.

#GPFUQ 144 How should GPs performance be managed? If you can’t measure it then how can they manage it? The outcome of the most important work in general practice is more a journey than a destination. The role, and the expectations, of primary care continue to expand, creating a need for a thoughtful process of rethinking the work on a regular basis. Everyone needs to be working ‘at the top of their licence’ most of the time. This will not happen without performance management

Suggestions for action

·               Stop thinking that the job of a GP is an art form

·               Stop thinking that most GPs are above average

·               Stop working in isolation, without your work being observed

·               Have annual in-house annual performance management of GPs. Neither NHS appraisal nor GMC revalidation are effective or useful in performance management.

·               Have in-house performance measures that are important and relevant in your team. Choose measures that may be a problem and will make a difference for patient care

·               Train, value and have career progression for non-clinical roles as well as clinical roles.

·               Tell and thank your staff and colleagues when things are going well

·               Aim for communicating and coordinating care better for patients in the different settings (health, social care, community, home), with better self care of patients, targeted ‘at risk’ groups and better preventative health for the population

#GPFUQ 145 Should GPs be assertive advocates for overall patient care like quality and efficiency - not just in their general practice 

The best organisations are more likely to tell people outside they are great. Good Practices exceed rather than meet patient expectations

Suggestions for action

·               Make sure care is coordinated and /or integrated across all elements of the system and the patient’s community, and that a patients referral is tracked, results are tracked, the patient is informed of the results and knows there was an interaction between his/her doctors. The patients learns what to do next and somebody asks the patient if everything turned out OK

·               Have an easy to use  template and process that you can use to report any problems with quality

·               Always ask 'is there something else you want to address in the visit today. It’s a more effective question than ‘is there anything else you want to address in the visit today?’

·               Don't be afraid of feedback and comparing results and processes

How did reflective practice become less like a mirror and more like a hammer?

#GPFUQ 139 How do you learn most from your experience? Some form of reflective practice usually improves learning. In modern times Donald Schön in The Reflective Practitioner (1983) promoted learning through reflection. Different writers suggest different models that can structure your reflection. The simplest is to ask yourself three questions: What? So What? What now?

#GPFUQ 140 How did reflective practice become less like a mirror and more like a hammer? If the only tool you have is a hammer then everything starts to look like a nail. Reflection has been seized as an essential tool for appraisers and written reflection the hammer to nail all learning when no theory, evidence or rule supports this use.

The GMC’s ‘Ready for revalidation - Supporting information for appraisal and revalidation’ says that good medical practice requires you to reflect on your practice and whether you are working to the relevant standards. When using supporting information in appraisal you should, through reflection and discussion at appraisal, have demonstrated your practice against all the attributes outlined in the GMC guidance ‘Good medical practice Framework for appraisal and revalidation’. This will make it easier for your appraiser to complete your appraisal and for your Responsible Officer to make a recommendation to the GMC about your revalidation. It is not necessary to structure the appraisal formally around the GMP Framework, or to map supporting information directly against each attribute. However, some doctors may prefer to do this and some appraisers may find it useful to structure the appraisal interview in this way. In discussing your supporting information, your appraiser will be interested in what you did with the information and your reflections on that information, not simply that you collected it and maintained it in a portfolio. Your appraiser will want to know what you think the supporting information says about your practice and how you intend to develop or modify your practice as a result of that reflection. For example, how you responded to a significant event and any changes to your work as a result, rather than the number of significant events that occurred.

The RCGP Guide to Revalidation v 8 Sept 2013 says you need to ensure that each of your annual appraisals covers the requirements for revalidation, and that you are sharing the required supporting information with your appraiser.

Your appraiser is key to your revalidation. Your appraiser reviews your supporting information with you and offers your responsible officer reassurance that your supporting information and your reflection on it are appropriate.

Personal Development Plan - It is very important that you reflect on the objective, the development achieved and any reasons for not achieving the objective. This reflection is an important attribute of your fitness to practise.

In summary you do need to be able to reflect on your practice with your appraiser but you don’t need to write reflective statements about everything that you record.

#GPFUQ 141 What sort of reflection aids learning? The theory is that you compare your current performance with desired competencies - by self assessment, peer assessment, or objective testing (see #GPFUQ 142)– then plan your education accordingly. Reflection on action is an aspect of experiential learning and involves thinking back to some performance and identifying what was done well and what could have been done better. The latter category indicates learning needs. Reflection in action involves thinking about actual performance at the time that it occurs and requires some means of recording identified strengths and weaknesses at the time. Self assessment by diaries, journals, log books, weekly reviews are an extension of reflection that involves keeping a diary or other account of experiences. However most people only write nearer the time of their review than the time of the activity being recorded.

#GPFUQ 142 What sorts of activity are best used for reflection? Feedback fuels reflection.

Peer review: involves doctors assessing each other's practice and giving feedback and perhaps advice about possible education, training, or organisational strategies to improve performance. There are five main types of peer review internal, external, informal, multidisciplinary, and physician assessment. The last is the most formal, involving rating forms completed by nominated colleagues, and has validity, reliability, and acceptability.

Observation: In more formal settings doctors can be observed performing specific tasks that can be rated by an observer, either according to known criteria or more informally. The results are discussed, and learning needs are identified. The observer can be a peer, a senior, or a disinterested person if the ratings are sufficiently objective or overlap with the observer's area of expertise (such as communication skills or management).

Critical incident review and significant event auditing; Although this technique is usually used to identify the competencies of a profession or for quality assurance, it can also be used on an individual basis to identify learning needs. The method involves individuals identifying and recording, say, one incident each week in which they feel they should have performed better, analysing the incident by its setting, exactly what occurred, and the outcome and why it was ineffective.

Practice review A routine review of notes, charts, prescribing, letters, requests, etc, can identify learning needs, especially if the format of looking at what is satisfactory and what leaves room for improvement is followed.