Monthly Archives: October 2015

GP in crisis: how does European family medicine compare?

IMG_0277Mary McCarthy is a GP in Shrewsbury., She is on the GPC and is interested in comparative health systems. She is the BMA rep to UEMO.

UEMO (Union Européenne des Médecins Omnipraticiens) represents GPs in 26 European member states. It develops policy and projects to support family medicine and to share best practice. It also provides an opportunity to look at other health systems and to learn from them, studying alternative ways of working and investigating ideas that may help with UK general practice.

Earlier this year, a questionnaire was circulated by the UK delegation that asked about workload pressures in the differing EU member states. A total of 25 states replied (Malta gave two answers for their public and their private health care systems) and although the data set is incomplete, it still makes interesting reading and an overview of the findings is presented here.

Different models, different responsibilities

Not all countries have registered lists of patients. Often it divides, as it does in the Irish Republic, into those that are covered by a means-tested state-led system who have to be registered to take advantage of the financial benefits, and those who pay privately for health care, either through an insurance-based system or through their own pocket.

Sometimes, as in France, there is no requirement to register but because insurance companies offer incentives, 90% of patients do.

In Europe, Family Doctors may act as gate-keepers, as they do in the UK, or as signposts where they just act as a conduit to secondary care. The second course means that they do not deal with chronic disease management so do not have the pressures that the increasing shift to general practice of disease management that used to be dealt with in hospital clinics. In many EU states, children are seen by paediatricians not by GPs and gynaecological problems are referred for examination and investigation to gynaecologists.

Elderly people who are resident in nursing homes may be under the care of Community Physicians or, as in Holland, Nursing Home Doctors. Mental illness may be referred directly to secondary care.

Workload and practice

List sizes vary from 600 per GP in Belgium to 3,500 per GP in Turkey and consultation rates per GP vary from 10 a day to 50 a day. This figure is confused by the fact that some replies counted telephone consultations as well where other nations just rated face-to-face consultations.

Group practices are gradually becoming the norm throughout Europe, though Belgium still has only 3% of practices with more than one doctor. In Italy roughly 50% of practices are group practices and in the Netherlands about 75%. The UK is still far ahead with more than 90% of practices being group practices. E also have larger groups of doctors. In much of Europe practices have 2-3 doctors as opposed to our average of 6-7.

Most have list sizes of 1600 or lower and that I itself makes for a less stressful environment. The working day generally approaches the normal for the working population of the country being 8 hours a day or fewer – in the Danish system GP surgeries close at 4 pm on Monday to Thursday and at 2 pm on Friday. The health of the Danish population does not seem to be adversely affected by this restriction of GP hours of access. However despite this 76% of EU nations feel that general practice workload is unreasonable and unsustainable.

If the nations that think the workload in general practice is reasonable are examined, they tend to have some factors in common. They have a normal working day – that is, eigth hours or fewer and mostly have a list size of 1600 or fewer per GP. They are more likely to have longer consultations and, of course, have easier access into secondary care beds. However, the factor that seems to be the most important is the number of patient consultations per doctor per day.

Consultation length and duration

Most nations have 15 minute consultations with the Scandinavian countries veering towards 20-25 minutes. Those nations with 25 consultations or less a day find general practice manageable. Those nations who either have telephone consultations or face-to-face consultations that exceed 25 patient contacts a day per doctor find general practice unsustainable. They have problems in both retaining GPs and in recruiting newly qualified doctors to a GP training programme.

Home visits

Most do little home visiting – though this may be due to the greater availability of beds in European countries. The UK has the lowest bed numbers per 100,000 population in Europe with France having double the beds and Germany three times as many. This means that admission of sick patients is more or less the norm, rather tha, as in the UK, making huge efforts to keep patients out of hospital.


A profession under stress is a profession at risk. Maybe the answer is simply to reduce access to EU levels; to restrict doctor-patient contacts, both telephone and face-to-face consultations, to fewer than 25 a day. It may be possible to divert some demands to pharmacists, nurses or other health professionals. It may be possible to educate the public to self-care, at least for minor illnesses.

General practitioners are expensive and time-consuming to train. It would be sensible to use their skills carefully.

Junior doctor pay changes will damage general practice: the trainee view

Picture 030(1)Ravi Parekh is an academic clinical fellow in General Practice in North-West London with an interest in Medical Education.

I am a GP registrar working in London and over the past few months I have felt increasingly apprehensive about the future of general practice training in the UK. The latest blow to our training comes in the form of the recommendations from the DDRB report on the future of doctor’s pay.1

This independent report states the GP trainee supplement should be removed (currently 45% supplement) and replaced with “a flexible pay premium” known as a RRP (recruitment and retention premium), with trainees paid for the amount of unsociable work that is carried out, and a possible flexible pay premium adjusted locally, to help target problems with recruitment.

Firstly, in the majority of cases, this change will mean a substantial pay cut as trainees progress from a SHO (ST1 and 2) to a registrar (ST3). A large number of hospital rotations will include a substantial amount of unsociable work, which currently is remunerated with normally between 40-50% banding on top of the basic salary. However, the new proposals will mean despite career progression, increased responsibility within a higher risk setting, and working far more independently in the registrar year, there will be a significant pay cut. This would equate to a substantial penalty for choosing general practice as a career.

The BMA have suggested that the recommendations would mean an average pay cut of 30% to GP registrars.2 In real numbers, this is equivalent to a £15,000 pay cut, with virtually no consultation with the GP community or GP trainees, and now with the BMA leaving contract negations, we have no voice to express our concerns.

Secondly, a number of trainees within my own scheme have significant financial commitments, including families, mortgages and other dependants. With the potential of these changes being imposed onto us in the very near future, this will have a considerable impact on our take home pay, with many of us having to think about whether the job remains sustainable. I fail to understand how this fits into the “drive in recruitment” the government wants to achieve, with the goal of 50% of medical graduates entering general practice by 2016.3

Thirdly, there is a need to examine closer the “flexible pay premium” the recommendations suggest can help replace the supplement and solve the problem with GP recruitment. They state these can be implemented in “some parts of the UK”, with no specifics on how much this would equate to, who would be eligible to receive this, who decides whether this should be provided and what protection would we have for this premium. As a London trainee, I have little hope that this will be provided to London trainees or any other trainees who live in an area of the UK where the recruitment for GPs still remains competitive, and given the increase cost of living in these inner city areas, the impact on us will be increased.

Finally, what message does this send to medical students and junior doctors thinking of general practice as a career? With constant negative press in the media, proposals for seven day working, increased pressures to stop A&E admissions and transferring more services from the acute sector to us in the community, it appears to be that general practice is being treated on one hand as the saviour for all the problems in the NHS with no real increased funding to match these expectations.

Interestingly one of the solutions from the government to reduce pressure on us appears to be hiring physician assistants in general practice. These are people with a health related degree who complete two additional years in University. They can take histories, examine patients, diagnose conditions and propose management plans.  These jobs are being advertised with a salary of £50,000 very similar to the current pay we receive as a GP registrar. These physician assistants need to be under the direct supervision of a GP, who it appears will still hold ultimate responsibility for the patient.4,5

So it appears the public are going to be seen in the future by staff who are not doctors, who have not gone through the rigorous GP training schemes, who have not sat the AKT or CSA exams and are likely to be paid significantly more that those about to become fully trained GPs. I hope my fellow GP trainees, qualified GPs and ultimately our patients are aware of what is being proposed for the future of primary care in the UK.



1.     Department of Health. Review Body on Doctors’ and Dentists’ Remuneration (DDRB) review for 2015: written evidence from the Department of Health.

2.     British Medical Association. Contract proposals for junior doctors.

3.     GP Taskforce Initial Report: Securing the Future GP Workforce Delivering the Mandate on GP Expansion.

4.     NHS Careers. Physician Associate.

5.     BMJ Careers. Physician assistants: friends or foes to doctors.

The Ten Commandments for patient-centred treatment

TenCommsGolden Calf Lehman_1Richard Lehman gives some background on the BJGP article The Ten Commandments for Patient-Centred Treatment published in the October issue.

The Ten Commandments for Patient-Centred Treatment had a gestation of nearly four years. And their true parent was John S Yudkin, Emeritus Professor of Medicine at University College London. In presenting this version for primary care doctors I have just been acting as a very slow midwife.

John’s original set of “10 Commandments for the New Therapeutics” first appeared as an addendum to my weekly BMJ journal blog in January 2012 and then in print in The Good GP Training Guide edited by Matt Burkes and Alec Logan.

With the help of John and our Canadian co-authors I have tried to apply the main principles of John’s original commandments to our daily practice. Their original focus was on long-term treatment which we all felt – back in 2011 – was being increasingly foisted on people without any attempt to explain the marginal benefit for each individual. A lot of it was not even informed by evidence of real long-term benefit or possible harm, especially for conditions such as type 2 diabetes and hyperlipidaemia.

Late that year John rang me to say he was writing a piece for the BMJ about these surrogate markers with two mutual friends, Kasia Lipska and Victor Montori. He was looking for the right word in the title – something to do with false worship. Not “heresy” but a bit like it. I suggested “idolatry” and did a riff about him being Moses on Mount Sinai getting commandments from God while the rest of the diabetes community were worshipping the Golden Calf of HbA1c. The next thing I knew, he had completed his much-cited BMJ Analysis piece called “The Idolatry of the Surrogate” – which inspired a wonderful illustration of totem worship on the journal cover. And at the same time he sent me his Ten Commandments.

The rest, I hope, is history. We would like these commandments to rapidly seem so obvious that they don’t appear either original or necessary. They are just about understanding patient goals and sharing information and good practice. If you can think of ways to make them better, just let us know.

The BJGP article Ten Commandments for Patient-Centred Treatment is available here

Download (PDF, 34KB)

BJGP Letter: A bleak future for future GPs in England

IMG_0976 (2)Guy Rughani is a Foundation Year 2 doctor working in North London. He wrote this short letter to the BJGP.

Contribute to the BJGP at

I want to be a GP, but the government is doing everything it can to stop me.

Mr Hunt’s brilliant answer to the crisis in GP recruitment is to slash trainee pay by 30%, penalise doctors taking maternity leave or extra degrees and extend normal working hours.1 Morale amongst my peers about to apply for specialty training is catastrophically low. As a result, the majority of my friends are looking to move from the NHS and take a ‘Foundation Year 3: FY3’ because they perceive that their immediate future here is bleak.  At a time in our careers when we should be optimistic and enthusiastic, it’s tragic that the state of the English NHS is leaving us so disillusioned. Scotland has dismissed the new junior contract, making a move North ever more tempting.

We need a strong positive message from senior doctors that there is a bright future in English General Practice, and a commitment from government that our incomes will be protected and our efforts valued.

1: BMA Junior and Consultant contract negotiations explained:

Review: An interoceptive moment with your neurobiological self

image001Alistair Dobbin is an honorary fellow at Edinburgh University medical school, an ex GP, a researcher and charity director.

Book Review: How Do You Feel?: An Interoceptive Moment with Your Neurobiological Self by A.D. (Bud) Craig.

Available at Princeton Press:

Groundbreaking scientific discovery sometimes comes through not accepting the status quo, for instance John Harvey’s discovery of the circulation of the blood. If you want a fascinating ride through the neuroscience of emotions (and cognition with which it is intricately linked) and a completely different formulation of how the anatomy and physiology work you should definitely read this book. Originally a mathematician Craig accidentally strayed into a neuroscience class where they were doing single cell analysis of the thalamus and he was hooked and changed course. Once he started studying the textbooks he was struck by a number of anomalies in the description of the sensory pathways from the body to the brain. He could not understand why the pain and temperature pathway took a completely different, contralateral, course to the ipsilateral mechanoreceptor (2 point discrimination, and proprioception) pathway.

k10405He has carried out a series of studies using many different methods of inquiry (all clearly explained in the book) sometimes spending weeks trying to isolate a single neurone in the thalamus. It turns out that pain and temperature (and many other sensations) are in fact homeostatic emotions; they provoke action repertoires to maintain homeostasis. This results in many new insights in mind/body links. There is little doubt of his findings, as he has done most of the science himself, led by the desire to integrate these findings into a systematic model.

The level of scholarship in this book is astounding, and indeed the classification of the homeostatic emotions is only the beginning of the story. For myself, a medical student in the 1970s this is a real gem. I regularly run workshops in Neuroscience for GPs and have been using his ideas to promote an integrated view of emotion and cognition; they lap it up. In the field of emotional distress the concept of oppositional inhibition of the left and right anterior insulae and the development and connectivity of the brain is a real game changer in this field. For example Craig actually delineates the connections of the C fibres carrying gentle affiliative touch to the principle emotional centres, in an integrative way, while at the same time explaining the evolution of the autonomic nervous system. Gentle touch is also a homeostatic emotion not a sensation. Some of the later chapters are challenging but overall the findings integrate and explain rather than confuse. Craig captures the spirit of renaissance creativity (the section on connectivity is fascinating, very much a fresh mathematical approach) and in years to come I am sure he will be recognised as a force majeur in neuroscience, as Harvey was for the circulation.

The AA – what GPs can learn from the 4th emergency service

Jessica DrinkwaterJess Drinkwater is a GP in Bradford and NIHR Doctoral Research Fellow at the University of Leeds. (Ed note: And she is a member of the BJGP Editorial Board.)

I am the worst type of car owner. I have never cleaned my car (I wait for the complementary clean following MOT). I don’t understand how they work. I know from the road works signs that I should check my tyres, fuel, and oil regularly, but I don’t. I am a bad car owner.

Instead I have AA membership.

So when a red warning light flashes up on the dashboard, I am alarmed but don’t panic. After a quick call to the garage I am informed it is likely the “alternator” and I should stop somewhere safe. I have no idea what an alternator is, but red means bad, so I stop. Thirty minutes later the AA man arrives (Tim). Within two minutes Tim has also diagnosed my alternator is not working. But what happens next is amazing.

Tim shows me where the alternator is, explains how it works, and how the engine makes electricity to charge the battery. With some gadgets he shows me how much electricity my car uses, and explains what will happen if I keep driving (abrupt halt in the middle of the road). He then outlines my options, the various risks, and the costs. All of a sudden I realise we are doing shared decision making. He is an expert. Within 10 minutes we have agreed a plan of action with him implicitly understanding my ideas, concerns, and expectations.

Tim agrees to change the alternator. Because I’m interested (and Tim likes talking) we chat whilst he works. I’m curious to discover whether he has had communication skills training (no), and how he knows what to tell people. He says he always gives an explanation to the customer. After a few sentences he can tell from the person’s eyes and body language whether they understand. If they don’t, he starts to find out about them (their job, their interests) and then modifies the explanation to fit their cultural context. The similarities in our jobs is clear, so I tell him what I do.

We get chatting about communication skills and general practice. He says he can normally spot GPs a mile off. He says most GPs talk at one level without any adjustment for the person in front of them, and this makes GPs hard to understand, inaccessible, and superior. The best GP he has had is a Polish GP who takes time to explain things, more importantly at a level he understands.

I wonder what else I could learn from the AA, and ask what GPs should do differently. He says we could start by addressing the small things, like running late. He tells me that the AA overestimate their time to arrival, specifically to ensure they arrive early. Arriving early gets the “consultation” off to the right start, and leaves the customer with a positive experience. I agree, Tim took thirty minutes to turn up, way beyond my expectations. He asks why we don’t run to time. I start to give a million excuses, the 10 min consultation, emergencies, workload, patients with multiple problems. But the reality is I routinely run 30 minutes late. If this is routine why not plan for it, put breaks in my surgery, and give patients a more accurate appointment time and better experience? It’s probably a combination of being seen to pull my weight and conform to peer standards. It’s definitely not because patients want 10 minute appointments and harassed clinicians.

I was left driving away reflecting on how often I modify my language for the patient in front of me, whether I should actually be modifying my practice for my patients, and how I can get an AA (wo)man to join our patient group.

Thanks to Tim Parrington for fixing my alternator and the stimulating discussion.

RCGP Conference 2015: Stephen Bergman on good patient care

UnknownStephen Bergman is a doctor, novelist and playwright. He is currently a Clinical Professor of Medicine in Medical Humanities and Ethics at New York University Medical School. His book, The House of God, published in 1978, is firmly established in medical culture and deservedly has wider ‘cult classic’ status.

In 1971, I wrote this piece, and recently have looked back at it. In a sense it has all the things I’ve learned since, and that every good General Practitioner learns. I give a little current comment on what in fact I have learned, at the end.


Samuel Shem 

Medical students in their course on diagnosis are taught: “When you hear hoof beats outside the window don’t assume it’s a zebra.” This means that you should think of common diseases first, not exotic ones. Decades ago when I was a medical student in Boston at one of man’s greatest hospitals, I was assigned a woman with “difficulty breathing.” She was 56 years old, a mother of three whose husband had died two years before. In good health all her life, she worked in a flower shop. She had never before had trouble breathing. Her husband’s death had been a shock, but with the support of friends and family she had gotten through it pretty well. The resident—my boss—came in and took his history, in a rat-a-tat technique of asking a probing question which had to be answered yes or no, and as soon as there was a response, cutting her off and moving on to the next—I knew he was filling in his grid, a decision tree that would provide the diagnosis. No new information came up. Physical exam showed nothing but her panting. Lab work revealed increased eosinophilia, the blood cell that increases when the body is allergic to something. The resident went back and grilled her on allergies. Nothing.

Her workup proceeded in classic academic fashion, with increasingly refined blood tests and X-rays. The latter showed a diffuse pattern of lung irritation, but no lesions or tumors. Experts were called in, and each diagnosed something in their area of expertise, from the psychiatrist diagnosing “melancholia” at her husband’s death, to the surgeons wanting to cut. She kept getting worse, the oxygen levels in her blood falling lower and lower, blueing her lips, paling her face. A look of doom seemed to cloud her eyes. The surgeons did a lung biopsy which showed only that her lung was reacting to some antigen, as the blood test had shown.

She continued to decline. Palliative treatment was begun. The resident and staff doctors seemed reluctant to enter her room. I felt scared for her and sorry, and spent more and more time sitting with her, just talking—a medical student has time for this arcane procedure. One day I asked where she lived. She said that after her husband died she’d taken in boarders to survive. I asked about them. “One of them’s…a real trip,” she gasped. “A magician.” I smiled and asked more about him. Part of his act involved trained pigeons, which he kept in cages in the basement. “The cages are right above my washer drier.” My ears perked up. It turned out that whenever she ran the drier, the pigeon droppings were aerosolized and she breathed them in—for the past two years. I rushed to the medical library—in those days we still used books—and found “Pigeon Breeder’s Lung Disease.” Treatment: get rid of the pigeons; and a course of steroids. Prognosis: excellent. The magician suffered. She got well.

Looking back now, what did I learn?

That the science of medicine is astonishing and useful, but it can keep us from practicing the human art of listening and responding, face to face, heart to heart, without a decision tree in mind or a computer on our laps so we stare into the screen instead of look into the eyes, all to “save time”. That the for-profit insurance industry dictates that we doctors don’t have time to listen to our patients if we want to get paid. That if we rely on technology and tests and neglect “being with” the patient, we may well miss the vital human facts that will solve the mystery and bring the cure. And that the patient is never only the patient, the patient is the spouse (alive or dead), the family, the house and who lives in it, the friends, the community, the toxins, the climate, where the water comes from and where the garbage goes. The patient is the world.

And finally that the “hoof beats” outside the window can be zebras—or, if you listen carefully, just the light steps of a common bird.

What I’ve learned since

I’ve learned that the delivery of good medical care is based on understanding, and communicating with the patient, the risk of isolation, and the healing power of good connection. Doctors now are into their screens, and the best ones are those who can type without looking at the keyboard. The real issue in caring for the patient based on two things:

Connection comes first: if you are in good connection, you can talk about anything; if you’re not in good connection, you can’t talk about anything (this, of course applies to life outside medicine—thnk of your spouse or partner).

It’s never only what you do or say, it’s what you do or say next. No one ever gets connection right all the time, we are always getting it wrong, mostly in little ways. The ones who are great with patients—and with spouses,  partners etc—are those who, when there’s a disconnect, note it, hold it with the other person, and then do something next to turn it into a better connection.

Good relationship, good connection, is the key to good patient care.  And GPs are lucky—you get to actually be with patients in this way.

RCGP Conference 2015: Reflections on politicians and policy

Screen Shot 2015-10-01 at 10.41.07Euan Lawson is the Deputy Editor of the BJGP.

Today was the first day of the RCGP Annual Primary Care Conference and the sun was out in Glasgow.

Jeremy Hunt turned up for the last two years but we were informed by the President, Mike Pringle, that he had a genuine excuse for non-appearance this year. Two years ago Hunt spoke without notes and with an engagingly informal approach. He did the same last year and the audience weren’t quite so charmed and the cosy style felt a little forced. This year, he would have needed more than his warm fluffy personality to charm the audience given the seven day working proposals. Although not here in person, Hunt’s presence loomed large in discusssions. Maureen Baker spoke with great passion and no little anger voicing the concerns of many GPs. The whole of the speech is available at GP Online. Regarding the recent seven day working proposals she made the RCGP position clear:

She was disparaging of Jeremy Hunt’s “so-called” new deal and demanded George Osborne ensure that general practice received 11% of the NHS budget by 2020.

Jeremy Hunt may have been congratulating himself on avoiding the stress of facing several hundred irascible GPs, but it was a good gig for Shona Robison, the Scottish Government’s Cabinet Secretary for Health, Wellbeing and Sport. She was good enough to provide the following summary of her speech:

As Scottish Health Secretary, I appreciate the opportunity to welcome GPs from all over the UK to Scotland and the City of Glasgow and your discussions this week at the RCGP Annual Conference 2015 will make an invaluable contribution.   In Scotland we are committed to collaboration with doctors, not imposing change but rather working in partnership.  We are  taking this approach with junior doctors, where we have said we will not impose new terms and conditions.  We are doing the same with GPs, where we are collaboratively developing a new contractual framework for General Practice in Scotland.

GPs are at the heart of local communities. Without the hard work and commitment of GPs and their professional colleagues, like nurses, pharmacists and physiotherapists, our health system simply wouldn’t be able to cope.

GPs care for families, but also effectively ‘look after’ the rest of the NHS, influencing by their decisions and actions a significant proportion of the activity of the whole system.

The Scottish Government has always been committed to supporting vital, front line health care services. Investment has increased in every year of this Government, and is now £80 million higher than when we took office.

However I know that GP workload is increasing, as is the complexity of health care; and where more is being delivered outside hospital settings, resources haven’t always followed in a proportionate way. The profession also faces serious challenges over recruitment, retention and increasing workload.

That is why we have been working with GPs, to agree on the good ideas and fresh thinking that are required to transform the way we provide care in Scotland.  This strategic approach puts GPs at the heart of multi-disciplinary teams of professionals, making a real difference to local communities. I have backed this work by introducing a £60 million primary care fund.

This money is being invested now in supplying new pharmacists to support GP workload, on GP leadership and recruitment and retention, on ensuring the future of the Scottish School of Primary Care and on testing new models of primary care in many parts of Scotland – from Deep End practices in Glasgow and Edinburgh dealing with inequalities to GP clusters in Grampian who are innovating in the way that they engage with their local community.

The future NHS must be very different from the past. We must develop new models of care, fit for the needs of the 21st century and the challenges ahead.

I am very proud of the NHS in Scotland. I know that General Practice is crucial to dealing with the challenges ahead. There is a firm commitment from the Scottish Government, backed by sustained investment, to continue to work with GPs to ensure the best for communities, for our people and for our families.

She saved the best for the speech itself and two promises sparkled in the Glasgow sunshine. Firstly, she announced a plan to dismantle QOF in Scotland. Yes, I know – apparently, it has “had its time”. And, finally, as befits a consummate politician she came circling back around to prey upon Jeremy Hunt. She was “appalled” by the actions of Jeremy Hunt and that the threats to junior doctors are “beyond the pale”. She offered no less than a “cast iron” guarantee that the Scottish Government will not be following Hunt’s plans to cut junior doctor pay.

The Scottish contingent of GPs were glowing and it wasn’t the unexpected dose of Glasgow UV on their faces. Those of us heading south face a long trip back in a day or two.