Author Archives: Roger Jones

Roger Jones

About Roger Jones

Roger Jones is Emeritus Professor of General Practice at King's College, London and is the Editor of the British Journal of General Practice.

Happy birthday to the NSPCR

Roger Jones

Roger Jones

Roger Jones is Emeritus Professor of General Practice at King's College, London and is the Editor of the British Journal of General Practice.
Roger Jones

The NIHR School for Primary Care research has celebrated its 10th anniversary.

Photo by MichelleBulgaria at Morguefile.com

Photo by MichelleBulgaria at Morguefile.com

Shortly after the National Institute of Health Care Research was established in 2006, with the aim of supporting applied health research for patient benefit, one of the first research Schools to be established was the National School for Primary Care Research, in 2006. The School initially consisted of the five top-scoring University Department of general practice in the most recent Research Assessment Exercise: the composition of the School has changed over the intervening years, so that it now consists of the primary care departments from Bristol, Cambridge, Keele, Manchester, Newcastle, Nottingham, Oxford, Southampton and University College London.

The school has just celebrated its 10th birthday by holding a showcase conference in the Wellcome Collection, London – not a bad choice of venue, because of the history of discovery and innovation embodied by the Wellcome Trust and also the Trust’s generous contributions to applied medical research funding over the years. Writing in the introduction to the conference programme, the Schools Director, Professor Richard Hobbs from Oxford, says that “The school was established by the NIHR in 2006 to increase the evidence-base for primary care practice. The school’s reputation to produce evidence with a patient-centred approach has influenced the development of policy, general practice, patient and public involvement and academic endeavour. Sound partnerships have strengthened the School over the years and collectively we offer a wealth of experience from a wide range of specialties and disciplines.” The School certainly has been a powerhouse of primary care research with a distinctly practical, clinical focus and a strong patient-centred ethos. It has made particularly strong recent contributions to the problems of antibiotic prescribing and resistance, and the management of atrial fibrillation and the use of prophylactic anticoagulation.

The introductory presentation to the conference was given by Professor Martin Roland, University of Cambridge, who was the first Director of the newly-founded School. Martin surveyed the key milestones in primary care research, beginning with the appointment at the University of Edinburgh of Richard Scott to the first chair of general practice in the world. Before running through the pantheon of the heroes of academic general practice, Martin paused to reflect on the malignant influence of one of the great villains of the piece, Lord Moran. He might have been Churchill’s physician, but he absolutely had it in for general practice. Famously, when he was giving evidence to the Doctors’ and Dentists’ Remuneration Committee of the BMA on the subject of merit awards, he was asked whether he agreed with the proposition that the two branches of the medical profession, general practice and consultancy, were not senior or junior to each other, but were on a level. Moran replied “I say emphatically no! Could anything be more absurd? I was Dean of St Mary’s Hospital Medical School for 25 years, and all the people of outstanding merit, with very few exceptions, aimed to get on the staff. There was no other aim, and it was a ladder off which some of them fell. How can you say that the people who fell off the ladder are the same as those who got to the top of it? It seems to me so ludicrous”.

Martin went on to describe the contributions of David Morrell, my own predecessor in the chair of general practice at Guy’s and St Thomas’s, and John Fry, the legendary single-handed GP from Beckenham, who laid the descriptive basis for clinical practice in primary care in the UK – two great founding fathers of general practice research. He explained how John Howie , Richard Scott’s successor in Edinburgh, negotiated for over 12 years to bring the Service Increment for Teaching funding out of the hospitals into general practice to support undergraduate medical education, how David Mant’s 1997 report on R& D in primary care exposed the order of magnitude under-funding and under-staffing of academic general practice and set a target for the proportion of R&D spend on primary care research, and how the Medical Research Council Topic Review, in the same year, led by Nigel Stott, focused the attention of the Council on research in general practice for the first time.

A previous director of the Wellcome Trust, Sir Mark Walport, produced his report in 2005 which transformed clinical academic training and in the same year the NIHR was established. The success and influence of academic general practice continued to increase, although it now may well have plateaued: only last year it was thought necessary to write an editorial for the BMJ entitled “Academic general practice: Visible? Viable? Invaluable”, and nothing can be taken for granted about the way in which general practice is viewed by the hospital specialties. In her recently-published report for Medical Education England “By choice – not by chance” Professor Val Wass reports on a “very powerful anti-GP rhetoric” in the medical schools and “an unpleasant cultural lack of care and respect for general practice”. Moran’s ladder casts a long shadow.

Looking ahead, Martin Roland thought that we should give some consideration to three questions. Are we, and do we want to be, the same as or different from academic colleagues in other disciplines? On the whole academic primary care leaders have thought it more appropriate, with more to gain, if we complete on an even playing field, but we must ensure that the playing field truly is even. Second, we should look inwards, and ensure that we are focusing on doing work of the highest international quality, likely to bring in the best Research Excellence Framework returns, which is genuinely useful to clinical practice in primary care. Finally we must think about ways of engaging across the NHS with other professionals, once again to ensure that research remains relevant to the needs of a rapidly changing health service.

A discussion session after the presentation touched on the relevance of academic primary care research to “real” GPs, their involvement in research networks and research projects, and their need for evidence-based practice. It is likely that proportionately more general practitioners are involved in research networks and in primary care research in the UK than almost anywhere else in the world, and by and large clinicians and primary care teams welcome the expanding evidence base for patient care in general practice. The NIHR School for Primary Care Research has achieved much already, and is likely to make a strong contribution in the years ahead.

“The best of times, the worst of times” for general practice

Roger Jones

Roger Jones

Roger Jones is Emeritus Professor of General Practice at King's College, London and is the Editor of the British Journal of General Practice.
Roger Jones

SIMON STEVENS AT THE NAPC

quotefancy-359812-3840x2160As well as signalling the end for QOF, the keynote speech at the National Association of Primary Care by Simon Stevens, chief executive of NHS, was a ringing endorsement of his strong support for general practice. Newly and handsomely bearded, Stevens confirmed that this new investment in general practice of £2.4 billion will be made by 2020, and encouraged the audience to “rattle the cage” to make sure that the promises made for additional funding for primary care are honoured in the CCGs’ investment plans and in the Sustainability and Transformation Plans, which are currently being written.

It seems to me that Stevens has “got” general practice for some time – he repeated the now-apocryphal quote from a BMJ editorial: “If general practice fails, the NHS fails” – and, according to him, the Department of Health has got it too. They have moved from denial, through acknowledgement, to the “action stage”. He went on to give a very upbeat assessment of the range of interventions that are currently being made to turn the service around – in a nice analogy he suggested that general practice is not an oil tanker, but a flotilla.

First of all recruitment – and he reported early signs of positive effects of programmes of work being undertaken in the medical schools to encourage students and medical graduates to see general practice as an attractive career choice. There will be an additional 1500 medical students in UK medical schools before long, and the challenge of keeping general practice teaching and departments of primary care on their radar is not inconsiderable.

Stevens also thought that there were some early signs of improvement in the numbers of returners to general practice, and recognised that for them, as well as for other GPs, such as those working in out of hours services, medical indemnity costs were proving significant barriers. He announced, in the speech, that £5 million or “whatever it takes” will be made available so that GPs are not “on the hook” when wishing to work at night and weekends.

He is very keen on expanding the non-clinical, non-traditional workforce in primary care. He reported that 485 clinical pharmacists are now working in the NHS, with 500 more planned each year for the next three years. There is funding for 3000 more mental health therapists, and 22 areas are already benefiting from this additional resource. He strongly endorsed the importance of practice nurses, practice managers and receptionists, and the importance of providing resources for external training and support for them.

He described the “Time to Care” programme, including 10 changes that can make a real difference to practices, such as dealing with the delays and costs associated with continued re-referring of patients between primary and secondary care. He also reported that over 800 vulnerable practices have been involved in the BMA/RCGP practice resilience program, and also recognised the importance of improving the built environment for general practice. He said that 560 practice improvement schemes have been completed, as part of the GP Infrastructure Scheme, with 316 in train, and 300 more announced on the day of his speech.

The Primary Care Home was a strong theme of the entire conference, and was touched on by Stevens, the report that this concept is being developed in 77 locations, where it may be possible to square the circle between this type of base general practice and the need to work at scale.

And it’s true – Stevens did say that this is the end of the road for QOF, which he said was “now nearing the end of its useful life”, and had descended into a box ticking exercise. New voluntary contracts are being developed as alternatives to current pay for performance arrangements.

Stevens was remarkably candid during an extended question and answer period. He was asked when the government would wake up to the need to charge patients to see their GP, and he replied that this was not what the country wants, and he had no intention of introducing charges. He was pressed by a GP registrar on how general practice was going to become a more attractive career option and by me on how he might turn the tide of early retirement, which is contributing to the workforce crisis. The answer to both is, of course, to be positive about the important role that general practice is going to play in the NHS of the future, the new opportunities for developing new ways of working, and achieving a better balance between work, family life and leisure. He also acknowledged that in important disease areas such as cancer and cardiovascular disease the NHS does not perform well in comparison with many OECD health systems, and recognised that much more will need to be done about early cancer diagnosis and cardiovascular prevention and disease management. Let’s hope that the oil tanker/flotilla analogy works, and it is possible to see some early “quick wins” in time to turn the tide.

Acute primary care in an integrated NHS

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

The tsunami of chronic disease management – the ageing population, rocketing rates of non-communicable diseases, and increasing complexity – have dominated much of the debate about the future of general practice and of the NHS. The crucial function of general practitioners in making accurate, timely diagnoses in patients presenting with acute symptoms is easily overlooked, yet is at the very core of primary care. The implications of this for mending the fractures in the system and for the design of integrated models of care came home to me in the course of three conferences over the last couple of weeks.

The first was a European meeting on screening for colorectal cancer, held in the Czech Republic, involving European Commission and Parliament policy-makers, as well as clinicians and epidemiologists. The focus was on increasing the momentum in member states of the EU to develop and extend screening programmes for colon cancer, which is an enormous health problem in Europe. However, the flip side of this debate is the fact that the huge majority of bowel cancers are diagnosed outside screening programs, either in patients presenting in general practice with suspicious symptoms or, in a substantial minority, in emergency hospital admissions for the complications of advanced disease.

The next was a conference summarising the achievements of the Discovery programme, a large, NIHR and charity funded research programme of research aimed at collecting evidence to support early cancer diagnosis in general practice (http://discovery-programme.org). One of many important messages for primary care was the need to be prepared to investigate patients with potential cancer symptoms much more promptly than we do at present, and the consequent requirement for better investigative services that can be readily accessed by general practitioners. Discovery investigators presented new data to show that many of the “typical” symptoms associated with cancer presentations are, in fact, much less common than more general,  often vague, complaints, such as fatigue and “feeling different”. They have also demonstrated that patients presented with vignettes of possible cancer scenarios are much more willing to undergo investigations at an earlier stage than previously recognised.

The third meeting was the Annual Conference of the South London Faculty of the RCGP which took as this year’s theme “Early diagnosis in general practice”. I presented some recently-published data, including the important recent BMJ Open paper from Peter Rose and a number of European colleagues which shows that GPs in England, Wales and Northern Ireland are much less likely to request investigations for potentially worrying symptoms then their general practice colleagues in most of the eight other European countries taking part in the study. Given the relatively poor cancer outcomes in the UK (and, for some reason, in Denmark), this is an important finding, adding weight to the need for speed and accuracy in investigations for suspected cancer.

Taken together, these studies and observations are powerful ammunition for the commissioning of better access to investigations, and for careful review of two-week wait criteria. They do, I think, mean more than this, and have major implications for the kind of integration between primary and secondary care that should develop within the NHS in the near to medium term future. In his Five Year Forward View, Simon Stevens, the NHS Chief Executive, describes two possible models of integration – the so-called Multi-speciality Community Provider (MCP) model and the Primary and Acute Care Systems (PACS) model. The first of these is a more horizontal integrative approach to community-based services, including of course general practice, whilst in the PACS model there is scope for a single provider organisation to deliver both primary and secondary care services, with no pre-defined requirement for this to be general practice-led or hospital-led.

The RCGP has, understandably, focused on developing the MCP model, which is probably more likely to keep general practice in the “driving seat”, and meets the five College criteria for an acceptable approach to integration. However, it seems to me that much might be gained by looking more positively at the PACS model, within which investigative pathways for patients with potentially serious conditions – and this of course doesn’t just apply to cancer, but to a host of potentially serious clinical problems – could be developed jointly between generalists and specialists. This approach could, I believe, lead to the creation of much less delay and misunderstanding by removing many of the barriers to speedy diagnosis and swift intervention that presently exist at the primary: secondary care interface. It would be simplistic to suggest that the MCP model is better suited to chronic disease management and the PACS to acute presentations and treatment, but that may not be far from the truth.

It is also possible to see other potential advantages of the PACS system, in locations where it would provide the most clinical benefit. A single employing organisation could provide economies of scale that the small-business model of general practice simply cannot achieve. Making use of joint infrastructures, including finance, HR, and procurement is likely to have significant cost benefits. Beyond this, the possibility that primary care specialists might be employed under similar contractual arrangements to hospital specialists, with benefits for continuing professional development,  career structure and work force planning, and with potential positive spin-offs for recruitment and retention, should not be underestimated or discounted.

When Simon Stevens spoke on the BBC’s, Andrew Marr show recently, he was candid in saying that general practice has suffered from 10 years of under-investment. The RCGP has done a terrific job in making this argument and articulating a strong case for substantially increased investment in the infrastructure and in the general practice workforce. Whilst the burden of an elderly, co-morbid and increasingly dependent population is undoubtedly making general practice creak at the seams, it will be important in the future – in the very near future, given the shortage of doctors wishing to become general practitioners – to look at how other professions can support the central role of GPs in delivering primary medical care. It will also be crucial for general practice to forge alliances with other parts of the health service and, when this is in the best interests of patient care, to collaborate, as well as lead, in new systems of integrated care likely to provide the best clinical outcomes.

The elephant in the room: how are we going to fund the NHS?

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

Last weekend The Times published a leading article which described the financial straitjacket in which the NHS finds itself, and suggested that the additional funding required to keep the service going should be found from sources outside general taxation. I wrote a letter supporting this view, pointing out that other healthcare systems, with perfectly respectable health outcomes, some better than ours, work on a combination or some variation of co-payment and insurance mechanisms. none of which, importantly, equate to privatisation.

I described this discussion as an elephant in the room – something that no one really wants to talk about and certainly won’t talk about in the run-up to the general election. I concluded by saying that I hoped the next government has the courage and gumption to bring into the open a discussion that everyone knows needs to take place, and which must take place if we are to preserve a national health service.

Extra money is going to be needed because the NHS is going to become increasingly expensive and there is going to be ever greater competition for money among government departments. A few years ago John Appleby, the chief economist at the Kings Fund, described three funding scenarios for the NHS – tepid, cold and arctic – and these three funding futures are reflected in Simon Stevens’ Five Year Forward View. Note that none of them are “comfortable” or “balmy”. It doesn’t require much detective work to read between some of the lines of this document to discern a lack of absolute certainty of the affordability of a publicly funded health system in the future. New models of integrated care may or may not turn out to be more cost-effective, but the NHS does not have a strong record on cost containment.

In my response to the Times leader I used the phrase “Those more able to pay for healthcare simply pay more”, and I don’t think that this is a bad mantra for the future of health funding in this country. It is consistent with social justice and I understand that there is some opinion poll evidence that it would not be an unpopular direction of travel for more affluent citizens. I think we have to tread carefully around the “free at the point of need” slogan – the NHS was never free – and we certainly would not wish to introduce a system in which health care providers need to see the colour of your money before treating you. It has been often said that the decency of a society can be judged by the way that it treats its most vulnerable and needy citizens. Requiring that the more fortunate members of our society make a greater contribution to the costs of health care could help to ensure that their less fortunate fellows continue to receive the care that they need.

Review: A Fortunate Man

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

A Fortunate Man: the story of a country doctor. John Berger and Jean Mohr. Canongate, London, 2015

First published in 1967, this is one of those must-read general practice books, essential for every trainer, trainee and practice library, and one, I suspect, which has been more frequently recommended than read. It has been re-issued this year in a new edition with an introduction by Dr Gavin Francis.

Anyone coming fresh to A Fortunate Man, expecting a paean to idyllic country general practice, will be disappointed, because the romanticised hero of John Berger’s extended essay is a deeply troubled individual to whom the epithet “fortunate” can be applied, at best, with irony.

Berger, now 88, is a distinguished critic and Booker Prize winner. He met the central character of the book, Dr John Eskell, as a patient in St Briavel’s, in the Forest of Dean, Gloucestershire, and became close friends with him. Eskell had been a Royal Naval surgeon during the war in the Mediterranean, and was now in single-handed practice following the death of his GP partner. Some time after Berger had left England for Geneva, Eskell, who becomes Dr John Sassall in the book, invited him and the photographer Jean Mohr to spend six weeks with his family and to shadow him round-the-clock in  his surgeries, on his many house calls and, presumably, in his domestic life, although this is not mentioned once In the book. Sassall was clearly a revelation to Berger, and the degree of connection, empathy, and acceptance that he showed to his patients, and the lengths that he went to, literally, to care for them are clearly regarded by Berger as both astonishing and exemplary. In describing Sassall’s actions and thoughts, and it is more often than not very difficult to know whether Sassall or Berger is doing the thinking, many of the core qualities and responsibilities of a general practitioner working in an isolated rural setting are perfectly captured.

However, Sassall’s hyper-commitment to his practice and his patients was, at least in part, a function of his manic-depression. Berger rather coolly describes Sassall’s lows, but doesn’t seem to quite understand the highs. Sassall’s wife, who ran his practice, died in 1981 and Sassall shot himself the following year. His professional life was troubled and he practised with little professional or, indeed, social contact. Whilst being admirably reflective and sensitive, he appeared to lack, or at least managed to avoid, any real recognition of his wider role as a general practitioner as an advocate for his practice population’s health or as a medical scientist. I can’t help making comparisons with Julian Tudor Hart, working wonders in Glyncorrwg, and John Fry laying the foundations of general practice research from his little practice in Beckenham.

I started reading this book 30-odd years ago and was put off by Berger’s often convoluted, freewheeling writing and Jean Mohr’s dreary photographs. I grew up in the Forest of Dean and, while recognising its comparative social isolation, bridled at Berger’s patronising depiction of Forest folk as uncultured half-wits, and still do. However, re-reading it at one sitting very recently, I recognised the limpid beauty of some of Berger’s prose, the subtlety of his descriptions of nature and of human interactions,  and his insights into the needs of ordinary people faced with illness, anguish and loss. His – or is it Sassall’s? – understanding of the role of the general practitioner as a witness and a “clerk of record”, needs to be widely understood, and never more so in these days of therapeutic miracles and performance indicators, when the unmeasurable essence of patient care can so easily be overlooked.