Monthly Archives: November 2015

Bristol and Exeter Student GP societies: working hard to promote general practice

Alice

Alice James is a 4th year medical student at Bristol University. She is passionate about promoting general practice to other students in her role as Chair of the University GP Society (Bristol GPSoc) and student representative for the Severn Faculty RCGP.

Nilakshini

Nilakshini is a 4th year medical student based in Exeter and is passionate about general practice. She believes it’s time to put the stigma associated with primary care behind us and start giving recognition for the challenging and exciting career that it really is.

The Bristol and Exeter Student GP societies aim to inspire members to consider a career in general practice through showcasing general practice as a versatile and fulfilling career and by challenging the stigmas associated with the profession by addressing controversial issues in the field. The societies provide CV-boosting advice, information about the GP training programme and hold events involving GPs with backgrounds ranging from conservation medicine and broadcast journalism to GPs with specialist interests.

Exeter student GP society, founded only in 2015, has initiated monthly practical teaching sessions for students in their pre-clinical years. This has been very popular so far and we are hoping to extend this mentoring scheme for students in their clinical years as well. This year the GP society are excited to introduce our inaugural debate under the auspices of Devon and Exeter Medical Society, ‘Are the increasing portion of female doctors, a key contributor for GP shortages?’. We hope that by addressing relevant and topical issues we can successfully challenge the negative stigmas associated with a career in general practice. Holding the event with the Devon and Exeter Medical society also provides students the opportunity meet and interact with general practitioners who are passionate about their career.

Bristol GPSoc, now in its 4th year, is planning to extend their annual conference to a full-day event to include student poster presentations and added workshops. The society is also planning a clinical skills workshop suitable for both pre-clinical and clinical years as an OSCE revision session. As well as stand-alone events, Bristol GPSoc has also joined forces with other University and Bristol-based societies. Last week the society held its first event of the year: ‘Mental Health: The Psychiatry-Primary Care Interface’ together with the Bristol University psychiatry society (PsychSoc). We heard from 2 local GPs, a consultant liaison psychiatrist and the founder of the mental health charity ‘Student Minds’. The 4 speakers addressed different ways of promoting better mental health by exemplifying methods used in their working environments. Approaches included peer support groups, self-care smart phone apps and services offered within GP services themselves including cognitive behavioural therapy (CBT) and self-hypnosis.

Both societies have benefited hugely from support given by local RCGP Faculties. Exeter GP society would like to thank Tamar Faculty for the funding and GP reading list which they have kindly provided. Furthermore, Tamar Faculty RCGP have recently co- opted the Chair of Exeter GPSoc onto their board as student representative. Following this, Bristol GPSoc enquired whether Severn Faculty RCGP had would be willing to open up a similar role on their board at the next AGM. As a result, the current Bristol GPSoc Chair was elected as the Severn Faculty student representative at the start of this month. Severn Faculty also allows other students to attend board meetings as observers and provides elective bursaries every year for Bristol students undertaking an elective within a primary care setting.

University backing is also essential to the development of student GP societies. Bristol GPSoc committee members have been invited to GP teacher training days and have been involved in the University-wide curriculum review by the Centre for Academic Primary Care. In addition, the University of Bristol medical student society (Galenicals) have given support by advertising events, providing funding and holding a medical student Freshers’ fair to promote student-led societies. Exeter Medical school also played a key role in setting up the GP society and are often good port of contact for the committee members.

At the most recent RCGP conference, one of the RCGP Associate in Training (AiT) committee representatives, Jodie Blackadder-Coward, organised a meeting for student GPSoc representatives from around the UK. This provided an opportunity to communicate ideas that we can then relay to a national body. Suggestions discussed by students and RCGP committee members included formal affiliation of GPSocs with the college, guidance on elective opportunities in primary care and deliberation of having a foundation year doctor on their GP committee.

Support from the RCGP and individual Universities will be fundamental to the continued growth and development of GP societies and to facilitate communication between them. We hope
both Severn and Tamar RCGP Faculties will continue to advertise the role of student representative to medical students in future years and that other RCGP Faculties will follow suit. Such opportunities have enabled both societies to voice our ideas and concerns with the hope of making an impact at both the undergraduate and specialty training level. The recently forged links between the GP Societies at the Universities of Exeter, Plymouth, Bristol and Cardiff have allowed us to share ideas and extend invitations to events. We have also discussed the prospect of a collaborative event to attract students and junior doctors from across the South West.

Junior doctors’ dispute – learning from previous experience

The First Cut Author photo 2Peter Sykes is a retired surgeon and author. His latest light hearted novel, entitled ‘First do no harm’ is set against the industrial action that beset the NHS in the 1970s. His website is www.petersykes.org.

Recently junior doctors voted overwhelmingly in favour of industrial action. It is a situation that they will not have encountered previously, indeed one that many will wish they didn’t have to face. They have many factors to consider when, as individuals, they decide just how militant they are prepared to be. No doubt they will weigh the pros and cons carefully. They may be helped in coming to their decision by considering the lessons learned during the last major dispute with the Government when, as now, junior doctors took industrial action.

In the 1970s, a situation arose that was remarkably similar to that at present. The juniors were negotiating with a Government whose main priority was to reduce public spending because of a burgeoning national debt. Harold Wilson and Denis Healey, Prime Minister and Chancellor respectively, were in the embarrassing situation of having to go ‘cap in hand’ to the International Monetary Fund for a loan to keep the country afloat. A strict wages policy was in place. In the weeks before the ballot, as now, there was relatively little coverage of the dispute in the press though the general public were thought to be broadly sympathetic to the juniors’ plight. Protest marches had been held and representations made to the Minister of Health, Barbara Castle but the Government remained unyielding and a ‘stand-off’ resulted. The mood was one of frustration and anger that genuine concerns were not being heard. There were strident calls in some quarters for a complete withdrawal of labour to force the Government to capitulate. A ballot of junior hospital doctors (JHDs) was arranged.

The ballot paper asked a number of different questions amongst them ‘Are you personally prepared to engage in industrial action and sustain this until the government provides extra money?’ Meetings of juniors were held up and down the country and there was a lively debate in the correspondence pages of medical journals. Some doctors were represented by the British Medical Association, others by the Medical Practitioners Union but a significant number had joined the more recently formed Junior Hospital Doctors Association which was significantly more militant. It rapidly became apparent that many doctors held extremely strong (though widely differing) views on the way forward and the advice they received from the three representative bodies varied enormously.

In deciding how to vote, juniors had many uncertainties to consider. Would it bring doctor into conflict with doctor; some in favour of action, others against? In fact it did; indeed before the result of the ballot was known, a vote of no confidence was passed in the Chair and Executive of the BMA’s negotiating group who were forced to resign from office.

What form should the industrial action take; would some doctors be willing, others unwilling to break the Hippocratic Oath? Who should decide on the form of action? A few spoke of complete withdrawal of labour; others argued that there should be no disruption to the service at all. As it transpired, it was left to individuals to decide and in practice, action was patchy. No one actually ‘went on strike’ and withdrew their labour completely. Some declined to take any action at all, others reduced their hours to 40 per week. Since the average number of hours worked was approximately 80, this had a profound effect and where this policy was implemented, all elective work ceased.

Then there was the question of patient safety; what safeguards would be put in place and who would monitor the situation? In the days before clinical governance, this was left to the conscience of the junior doctors. In the event, there were no reports of disruption to the care of accident and emergency patients.

A major concern was that doctors would damage their career prospects by taking action against the wishes of consultants, some of whom were keen to remind their staff of the hours they had worked when they were juniors! At this time, many consultants were refusing to sign the ‘overtime claims forms’ to sanction payment for work undertaken even though the juniors had a contractual right to such payments. This became a major issue between the juniors and the government who believed that the number of hours of overtime claimed, represented the amount of overtime worked.

A further complication was the major disagreement amongst the juniors as to whether the dispute was about pay or about the principles embodied in the proposed new contract. Is the present dispute principally about pay or is it about safe medical practice? The vote in favour of industrial action, published in November 1975, was 7355 to 5336 (the nature of the action was undefined).

When industrial action began, many failed to anticipate the close examination the press then gave to the junior’s pay and working conditions. This was a time of national financial crisis and support was not universal; some considered that everyone should make sacrifices to help the country through its economic difficulties. Similarly, they were unprepared for the criticism that resulted when patients suffered – as they inevitably did. In 1975, the number of patients treated in hospital was 4% lower than in 1974. The number of patients waiting for admission rose by 12% to the highest level since the NHS began and out-patient attendances were down by 7%. The reputation of the junior doctors was tarnished.

In that previous dispute, there had been no prior agreement of exactly what the government would be required to concede for the industrial action to be withdrawn. In fact, action was discontinued when a contract based on standard pay for a 40 hour week was agreed and an understanding reached that the rate of overtime pay should be determined by an independent body; the juniors therefore returning to normal working before they knew what the financial settlement would be. It was also agreed that the department of Health and the BMA would work jointly to reduce JHD’s excessive hours.

There are lessons to be learned from the JHD’s previous dispute with the Government and it would be wise to heed them. It is hoped that the Department of Health and the junior doctors will resume constructive dialogue so that industrial action, with the inevitable harm that will cause to patients, may be avoided.

Sources

Archives of the British Medical Association
Archives of the Royal College of Nursing
Archives of Confederation of Health Service Employees
Hansard
‘The Castle Diaries 1964 – 1976’ Barbara Castle
‘Fighting all the way’ Barbara Castle
‘The Red Queen’ Authorised biography of Barbara Castle. Anne Perkins
‘The Junior Doctors Pay Dispute 1975 – 1976 Susan Treloar
‘A history of the Royal College of Nursing 1916 – 1990’ Susan McGann, Anne Crowther and Rona Dougall
Lord David Owen Personal Communication

 

BJGP article on practices in special measures: CQC response

Devin GrayDevin Gray is a National Medical Director’s Clinical Fellow and a GP trainee, interested in driving system-level change to achieve better care and outcomes for patients.

This article was co-authored with Professor Nigel Sparrow OBE, Senior National GP Advisor and Responsible Officer, CQC and Professor Steve Field CBE, Chief Inspector of General Practice, CQC.

Thank you for the BJGP article, “CQC Inspections: unintended consequences of being placed in special measures”.The CQC welcomes opening the door to dialogue and discussion about practices being placed in special measures and wholeheartedly agrees with the need to work effectively together in enabling improvement.

Improving care under pressure

With unprecedented pressures in General Practice and across the whole NHS, we are aware of the context. Preparation for a CQC inspection may feel to some GPs as yet another task there is little time or resources for. So why engage with regulation?

At the CQC we are passionate about improving standards of quality and safety in healthcare. Through our work, we are for the first time able to provide a comprehensive description of what good care looks like.2 We support change and improvement by identifying and championing examples of good and outstanding practice, as demonstrated by our Outstanding Practice Toolkit,3 and by celebrating innovative ways of working in an ever resource-squeezed environment.

The intention of special measures

We do not underestimate the difficulties of being rated as inadequate for practice staff and patients. The intention of placing a practice in special measures is to make patients, providers and commissioners aware that we have serious concerns and to identify the need for urgent support. The special measures framework allows the CQC and NHS England to work together to ensure a timely and coordinated response to inadequate practices. It also provides clear timescales for addressing inadequate care, which was identified as missing in the case of Mid Staffordshire NHS Foundation Trust,4 allowing practices to access the support they need to get “back on a path to recovery and then to excellence”.5

The key is effective leadership

We have found that the vast majority (84%) of England’s GP practices are providing a good or outstanding service to their patients, with 12% rated as “requiring improvement”. So why are 4% of practices falling significantly short? As highlighted in the CQC’s recent State of Care report6, the key may be in leadership.

The CQC assesses the leadership and organisational culture of providers, rating them on how “well-led” they are. By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

As highlighted in your article, every practice in special measures has been rated inadequate in the “well-led” key question (in addition to being rated as inadequate in one or more of the other key questions – safe, effective, caring or responsive). Perhaps there is no better time to be considering the role of effective leadership in providing high-quality care as well as guiding practices through these difficult times.

“The NHS needs leadership of the highest calibre if it is to respond successfully to financial and service pressures that are unprecedented in its history.”7

The first practice to come out of special measures was only recently announced. The process of regulation has driven impressive levels of improvement in this practice in the six months since its initial inspection: “In contrast to our last inspection, we found a group of
GPs and nurses providing clinical care at the practice who were enthusiastic, motivated and co-operating well with one another8 and four of the five key questions ratings improved.

The process of turning a struggling practice around no doubt involves significant time and effort. Improvement does not happen overnight, and it does not happen without effective leadership. Investing in leadership has shown time and time again9 to pay off in the ongoing running of a well-led organisation that delivers good care to the population it serves.

Getting the right support at the right time

As mentioned in your article, there can be local awareness of issues long before the CQC inspects. In some cases, practices themselves have not been surprised by the rating. The CQC strongly supports the early identification of problems within a practice and early investment in support, rather than waiting for an inspection itself to raise the profile of the issues. This will involve closer collaborative working with Clinical Commissioning Groups (CCGs), NHS England and other members of the local health economy.

“At a time when there is growing interest in integrated care and partnership working between the NHS, local authorities and third sector organisations, collective leadership in local health systems has never been more important or necessary.”7

Looking to the future

As our health care economy continues to evolve, and new models of care emerge, the CQC is committed to understanding how we can best work together to support and champion change, and improve quality of care. Crucially, as a profession we must not let regulation act as a barrier to innovation.

Whilst there will be a few practices that need little more than hard resources to improve standards, our findings support a strong argument to be investing in leadership within practices. This has been a central theme in supporting Acute Trusts in special measures, and should be for General Practice. In recognition of this, the CQC is working collaboratively with other organisations to improve our assessment of leadership and organisational culture going forward.

We welcome the RCGP’s commitment to leadership development and its Pilot Scheme has clearly been doing essential work. Nevertheless, we must take more collective responsibility in identifying struggling practices early, championing innovation, driving improvement, and providing long-term support.

Deputy Editor note: If you do have any general points that you wish to put to the CQC please leave a comment. In the spirit of the article and the desire to have an open discussion they have promised to respond. However, please keep these to the general rather than raising specific concerns about specific practices.

References

1. Rendel S, Crawley H, Ballard T (2015) CQC inspections: unintended consequences of being placed in special measures, Br J Gen Pract DOI: 10.3399/bjgp15X686809
2. CQC: GP Practices Provider Handbook Appendices. March 2015
3. http://www.cqc.org.uk/content/examples-outstanding-practice-gps (accessed 6/10/15)
4. The Francis Report (Report of the Mid-Staffordshire NHS Foundation Trust public inquiry) and the Government’s response. December 2013
5. Department of Health: Hard Truths. The Journey to Putting Patients First. January 2014.
6. CQC: State of health care and adult social care 2014/14. October 2015.
7. The King’s Fund: Developing Collective Leadership. May 2014
8. http://www.cqc.org.uk/content/gp-practice-exits-special-measures-following-improvements-patients-1 (accessed 6/10/15)
9. The King’s Fund Commission: The Future of Leadership and Management in the NHS. No More Heroes. May 2011

Refugee medicine: time to get our act together

RFarringtonRebecca Farrington first worked overseas with refugees 20 years ago for MSF.  She is now a GPwSI in refugee mental health having worked in the UK as a GP with people seeking asylum for 10 years. She combines this with a clinical lecturer role at the University of Manchester and GP locums.

Last month I joined Turkish, Dutch, Swiss and Irish GPs to run workshops about refugee children at Wonca Europe in Istanbul. The topic is hot and was mentioned by many speakers. Wonca produced a valuable statement encouraging doctors across the continent to uphold a migrant’s rights to equitable care “unconditionally and based on a set of core values” fundamental to the practice of family medicine.

So how can we in the UK respond to the challenges? Delivery of primary care for asylum seekers in the UK is fragmented.  We have NGOs and foreign aid agencies in our cities struggling to find NHS care for the most vulnerable. There is undoubtedly goodwill amongst the GPs I meet, interest from trainees and First 5 doctors in knowing more, but there is little in the way of infrastructure and training. GPs are expected to ‘get on with it’, but asylum seekers are challenging patients. They don’t trust you and can’t navigate your system. They are often distressed, some having experienced trauma that is beyond your comprehension. Their priorities can be low on Maslow’s Hierarchy – safety, warmth and legal representation. Freedom from pain, often tied up in their expression of psychological distress, is a frequent demand. Most are socially and financially deprived, living in fear, and we know their health deteriorates in the asylum system.

It’s scary to ask the question ‘what happened to you?’ – even scarier when you only have 10 minutes and perhaps are under pressure to use inadequate or inappropriate interpretation. Disclosure can be traumatising for the practitioner and the patient. Who wants to end the consultation feeling worse? So to “screen and promptly identify cases of violence and abuse, prevent them and intervene in collaboration with the relevant authorities and community resources” can feel quite daunting. We are there to provide health care, not decide their asylum claim, but many have complex medicolegal needs that remain unaddressed without our advocacy as their doctors.

For 7 years in Salford we had a PCT-managed asylum seeker surgery. We developed expertise and, just as important, we looked after each other. We had good interpretation and excellent links with the voluntary sector. We knew how to write letters that actually made a difference for patients. In 2012 we were closed following a failed tendering process: there were no ‘willing providers’. No one ever said we weren’t doing a good job, but there was ‘no way’ to commission it directly in the new structure.

Salford CCG and GMW Mental Health Trust now support me to work as a GPwSI but we all recognise its limitations especially in overcoming the barriers to access. With an influx of new refugees – people with the same hopes, dreams and fears as you and me – what are we actually going to do to ensure “sustainable and uninterruptable provision of comprehensive and integrated health care”? Our response to this is the ‘canary in the mine’. If we can get this safety net right for our most vulnerable then other disempowered, communities will also benefit.

People seeking sanctuary arrive on their knees. If we can give them a hand up we will have a young, fit population keen and able to contribute to our economy. If we don’t, we risk social alienation and a chronic disease burden that can be prevented.

In the North West we propose a hub and spoke model: GPs and nurses with specialist knowledge and skills supported by local practices sharing care. Innovations in IT with remote access to notes and co-production by refugees themselves, many of whom bring professional skills, can make for safe, appropriate, culturally sensible and patient-centred care. Strong primary care is an economically sound investment for this group and at such a hub we could provide workplace training in social medicine for our new GPs.

There are people in the UK who know what needs to be done. Many of us were doing it prior to 2012, but we need an infrastructure to support us. John Yaphe at Wonca said “We need the head, the hands and the heart to make it happen”. I would add we need the political will, and that we should move now to turn talk into action.