How often will GPs see a condition that statistically they will never see?

#GPFUQ 181 How often will GPs see a condition that statistically they will never see?  About once every ten years.

#GPFUQ 182 Can GPs increase patients self treatment and reduce the need for medical involvement?

If GPs don’t do the work – will GPs lose their special relationship with their patients? General Practice can be like being a good parent it involves not just quality time but also routine stuff so being a good GP means being available for the minor worries, coughs and travellers' diarrhoea as well as for major physical and psychological pathology. By dealing with the former GPs can build the relationships they need to be able to help with the latter. However many minor ailments could be self managed. IMS Health survey Dec 2007 shows 57m GP consultations annually involve minor ailments, (51.4m involve minor ailments alone), 18% GP workload is for minor ailements, 50% Minor ailment consultations are for 16-59yr olds, costs to NHS £2b pa (80% are for GP time), averages 1hour/day for every GP http://www.pagb.co.uk/information/research.html#tns

Suggestions for action

·               GPs should develop a strategy for promotion of self-treatment of minor ailments, and a triage process. Setting up self-treatment facilities and advice.

·               RCGP should script Video and podcasts for use on the practice website and in the waiting room that tell patients how to look after minor ailments. Use the same RCGP script in different practices but with the local GPs as the ‘actors’ to promote local interest and validity. The video and podcast are accompanied by a printed handout on the management of minor ailments. You can have video added to video broadcasts in waiting room

·               Set up an ‘Avoid the queue, self manage your illness’ area in the practice to advise on initial best management for the following conditions which are the commonest minor ailments back pain, dermatitis, heartburn and indigestion, nasal congestion, constipation, migraine, cough, acne, sprains and strains, headache, earache, psoriasis, conjunctivitis, sore throat, diarrhoea, haemorrhoids, cystitis, hay fever, warts, nail infections, colds.

·               Produce an evidence-based handout on How to manage your minor ailment for each of the common minor ailment conditions.

·               Identify patients who have presented with minor ailments from the consultation records of the electronic health record and after the consultation mail the patient the information sheet How to manage your minor ailment for the relevant conditions- invite patients to return feedback sheet to enter into a prize draw

·               Gain greater value from previously under-utilised sources. This may include: enabling patients, carers and communities to manage and improve their own health and/or contribute to the process of healthcare; empowering members of the healthcare team whose contribution is at present limited owing to lack of training for example; and/or removing barriers that are standing in the way of obtaining full value from all members of the healthcare team eg ‘practice to the limit of the licence’

·               Triaging, consulting and prescribing for common benign conditions without red flags e.g cold, sore throat, UTIs in women, acne minor skin problems etc. Transfer most care of minor illnesses to triage by others and taught self care

·               Getting experienced staff to deliver some of doctors duties, i.e writing prescription for minor illness

·               Use local newspaper adverts about management of minor ailments

·               Provide more information for patients to record and track their symptoms and signs eg A one page leaflet to record and track symptoms of pain

·               The RCGP should publish a template for best practice

#GPFUQ 183 How should GPs assess their professional networks? Ask can you find and spread best practice any faster? The success of social networking websites shows how quickly networking tools spread. A ‘spread strategy’ is being part of an effective network of knowledge that works for you. Networking in one shape of form seems the most usual way that GPs already spread ideas. Formats include any professional meeting, peer group discussion and social events in practices and other group meetings and discussion in the wider world  (e.g. focus groups, internet groups, site visits, conferences, educational meetings, email communications, the media medical press, networks like CHAIN, doc2doc, Resilient GPs on Facebook, other social networking, chiefs meetings, champions, GP cooperatives, practice visits, annual appraisal, study groups, and on-line discussion groups). Most of these meetings are part of the professional and social fabric of the world we live in, and the networking is mostly unstructured and informal. However although it is clear that this networking connects almost everyone,  it may need improvement to make it more efficient and effective e.g. keeping up to date knowledge on any clinical topic like diabetes will be more robust if you can link with more than one network source about diabetes. Many of these networks have become prescribed with the formative processes involved in annual appraisals, and the various practice inspections (e.g. trainers reaccreditation) and provide a regular process of checking that every GP is part of a functioning professional network. Modern general practice where we work in groups and often have special responsibilities for certain clinical areas in the practice favour a networked approach to learning and being clear how each of us is connected to these networks for updating our knowledge and skills.

Suggestions for action

·           Map out your main networks and document them (who they are and what they link you to) for your next NHS appraisal. At your appraisal discuss whether there are any important clinical or business gaps in your links. What can you do to improve the efficiency and effectiveness of your networks? Circuit testing your learning networks at an annual appraisal process is a simple way to check up on the networks that each GP relates to. Whilst its too difficult to document all the networks, its is reasonable to test and trace the networks with hypothetical questions like how would you be confident that you would learn about and discuss a new innovation in practice management or new evidence in a treatment

·               Meet regularly with local colleagues to discuss difficult cases or to reflect on where they are and what can/must be improved

·               Buddy up with another practice to share expertise and resources

·               Look outside medicine and learn from business colleagues and friends

·               Have a relationship with secondary care colleagues- so that you can resolve local problems easily

·               Meet with wider social care/community nurses regularly to discuss patient referrals

·               Visit neighbouring practices to see what works well then discussing it at practice meetings to see whether the practice could learn from this

·               Continue any regular meetings with other GPs that has an agreed task of say support and sharing good ideas – and clear achievable and measurable aims eg Balint groups / Learning groups / Co mentoring

·               Undertake an evidence-based journal club weekly for 1 hour

·               Encourage all staff to attend practice meetings, not just partners. Involving them means they're more engaged with the practice.

·               RCGP should promote network groups- Unofficial groups abound, particularly among recent CCT holders. Make a census so they're known about.

·               The RCGP should publish a template for best practice

#GPFUQ 184 How do you improve GP? You need the feedback you can get either from a mirror or from a village

Whats wrong with the regulators?

#GPFUQ 177  What’s wrong with the regulators? A paradox of the new regulation of professionals like GMC Revalidation and the Care Quality Commission (CQC) that aims to reduce unacceptable variations in their performance is that the regulation itself can create unacceptable variations in regulation with poor quality assurance of both the structure and process of regulation creating variable outcomes. 

#GPFUQ 178  When is it the best treatment to stop medicines? If it improves patient outcomes. Risk can outweigh benefit when too many medicines are prescribed in patients with too many co-morbidties. Reducing and stopping drugs can then become the best treatment. There are 5 steps (1) check  all drugs the patient is taking and the reasons for each one; (2) consider the overall risk of drug-induced harm in individual patients before a  deprescribing intervention; (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential; (4) prioritize and agree with the patient the drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes; and (5) implement a discontinuation regimen and monitor patient  for improvement in outcomes or onset of adverse effects.

#GPFUQ 179  What’s the problem recording shared-decision making (SDM)? The use of electronic templates to gather data for whatever reason has shifted consultations from being patient-centred to computer-centred. The paradox is that the more time we spend recording SDM, the less time we have to actually do it.

#GPFUQ 180 When shouldn’t we ask for extra money for health care? If we are already spending money doing something pointless, or if we are looking for technical solutions to existential problems.

Who wants to be a GP?

#GPFUQ 171 Who wants to be a GP?  Surveys of UK medical graduates show that in the 1970s, over one-third of all newly-qualified doctors wanted careers in general practice, rising to 44% in 1983, but falling to 20% in 1996. A study in 2011 of cohorts of 2000, 2002, 2005, 2008, and 2009 showed the percentages of doctors who expressed an unreserved first choice for general practice in the first year after qualification, in the successive five cohorts, were 22.2%, 20.2%, 23.2%, 21.3%, and 20.4%. Percentages who expressed any choice for general practice, whether first, second or third, were 46.5%, 43.4%, 52.6%, 49.5%, and 49.9%. Three years after qualification, an unreserved first choice was expressed, in successive cohorts, by 27.9%, 26.1%, and 35.1%. Doctors from newly established English medical schools showed the highest levels of choice for general practice.

Information about early career preferences matters because early choices for general practice are highly predictive of eventual careers. For example, in previous cohorts 82% of doctors who specified that they wanted to become GPs in year 1, and 92% who specified this in year 3, eventually practised as GPs.

#GPFUQ 172 How do medical graduates choose a career?  We don’t know but likely influences  include,  student perspectives of the demands, rewards, and prestige of the specialty; national dialogue about health care reform; turbulence in the economic environment; lifestyle issues; the advice in medical school, the impact of faculty role models, peer group pressures and the availability of opportunities.

#GPFUQ 173 Will we have enough GPs in the future?  We can hope. The production of all doctors and GPs in particular remains insufficient to meet the current and anticipated need to support the UK's NHS infrastructure.’

#GPFUQ  174 How does learning happen in general practices Most learning in small organisations takes place in the workplace through work processes. It is multi episodic, mostly informal, usually problem based and takes place on a just in time basis. Despite the reality of how we actually learn, most organised learning on offer still tends to be based on a traditional model with modules, lectures and seminars and these are increasingly transferred from face to face interactions to onscreen interactions, but still keep the standard tutor/student relationship and the reliance on formal and standardized course material and curricula. Reviews of the effectiveness of  "traditional" style e-learning in health care show that there is little evidence of change in behaviour or improved patient care and suggest that change in behaviour requires a social /collaborative approach that allows the exchange of explicit and tacit knowledge. Such social/collaborative approaches applied face-to-face have been shown to work when bringing together professionals to share their experiences and learn together using problems based on their own working experience However, attempts to introduce online collaborative learning have often failed, perhaps due to a lack of understanding of the health care context and user requirements.

#GPFUQ 175 What is Bellman medicine? The belief that repetition is a form of validation. It’s from The Bellman in Louis Carroll’s The Hunting of the Snark. It’s the continued presentation of discredited data, or the disregard of data from an another study which comes to a different conclusion

#GPFUQ 176 What’s the latest in educational reform? Three generations of educational reforms characterise progress during the past hundred years. The first generation at the beginning of the 20th century taught knowledge from a science-based curriculum.  Around the mid twentieth century, the second generation introduced problem-based learning, and taught any relevant knowledge that would help solve the problem.  The next generation is now evolving.  This is systems sourced solving and is will provide a work environment in which core professional competencies get automatic support and teaching in specific contexts, whilst drawing on global knowledge to improve the performance of health systems

How to become President of the RCGP

#GPFUQ 170 How do you win a presidential RCGP election? You need 95% luck and a 5% mix of knowledge, skills, understanding, and self belief. This is the result of the 2015 election The president is the only College Officer position elected by the whole College membership in a national ballot and it uses the single transferable vote system.  This year 7,325 (20%) of the 36,735 eligible voters voted and I won each round of the voting. I was the first choice of 26% (of 4 candidates), and 51.8% (of  the final 2 candidates). My final 3,184 votes represents 8.7% of the eligible votes. Equal numbers of votes were cast by post and on line. At the last election in 2012 5,174 (16.4%) of the 31,623 voters (86% by post). Mike Pringle won the final vote with 2438 (59%) of the final 2 candidates. His final vote represented 7.7% of the eligible votes.