Do we risk sacrificing our effectiveness as clinicians in the name of convenience?

31 July 2020

What will be the likely balance between remote and face-to-face consultations in general practice when we reach a post-pandemic steady state? Before COVID hit, 75% of consultations in general practice were face-to-face.

Now, according to the RCGP Research Surveillance Centre data, it’s about 30%, up from a low of just 15% at the peak of the crisis.

I say 50:50 on the basis of nothing but a finger in the air. Others say 80% remote. Some policy makers apparently want a 'remote-by-default' position, except when the clinician decides otherwise. This doesn’t feel very patient-centred to me and is unlikely to be attractive to most doctors considering their career options.

The responses have got me thinking about what I gain from being in the same room as my patients.

The direct and indirect benefits of the laying on of hands is the most obvious benefit but it’s about more than that. How important to my clinical decision making is seeing a worried look, a tearful eye, pallor, a tremor, sweating, an altered gait? Or smelling stale urine on someone’s clothes or alcohol on their breath? Which of these signs will I miss on a telephone or video call?

We can do so much more remotely than we thought possible but we need to be honest with ourselves and our patients. Do we risk sacrificing our effectiveness as clinicians in the name of convenience?

COVID-19 update from your College

Future of healthcare

Related to my introduction above, one policy maker who likes the idea of a 'remote by default' system of general practice is Health and Social Care Secretary Matt Hancock, as he made clear in a speech on the future of healthcare yesterday.

While we agree with the Health Secretary that we need to learn lessons from the different ways we’ve been working during the pandemic, we also need to remember that this has been out of necessity. Long-term, a totally, or even predominantly, remote general practice service is not desirable. We want to be able to offer patients a choice about how they access our care to best suit their needs and preferences. I spoke about this on BBC Radio 2’s Jeremy Vine Show (about 1h 35m in) and have been featured in a number of news outlets today, including the BBC, The Times, Daily Mail, The Guardian and the I. Thanks to joint Hon Sec Jonathan Leach, Vice Chair Michael Mulholland and Vice Chair Mike Holmes for making the College’s case on Times Radio, LBC and Talk Radio respectively.

This was also a key point raised in the latest #RCGPTogetherLive webinar I hosted last night on relationship-based care. I was joined by our Patient and Carer Participation Group Chair Owen Richards, RCGP Scotland Executive Officer Graham Kramer, Person Centred Care leads Mohan Sekeram and Gwyn Elias, and Jennifer Vorhees, a GP and health services researcher from the University of Manchester - thank you all for taking part. We discussed how remote working fits in with being able to deliver continuity of care, and each made a pitch to decision makers as to why they should prioritise relationship-based care. If you weren’t able to join, you can watch it back.

One very welcome theme in Mr Hancock’s speech was his desire to cut bureaucracy in the NHS - the College is already working with Health Minister Jo Churchill on this as part of her ministerial working group on the future of general practice. As GPs, we have shown throughout the pandemic that we can work safely and in the best interests of patients without spending hours of our time paper pushing. As the College has said in our recent General Practice in the Post-Covid World report, we need to move towards a higher-trust system of regulation and compliance, with less 'tick box accountability', and in turn free up our time for patients.

The third theme I wanted to mention from Mr Hancock’s speech was workforce, as it corresponded to NHS England and Improvement’s People Plan being published. Of course, work on the Plan has been interrupted, first by the General Election, then the pandemic, and we understand that much will rest on what’s in the Comprehensive Spending Review this Autumn. But it was still frustrating to see a lot of decent aspiration - including to build the GP workforce - but without the detail on how it will be delivered that we’ve been long calling for.

The College will continue pushing for a solid strategy on how the 6,000 more GPs, promised by the Prime Minister more than a year ago will be delivered - and in particular we want to see robust initiatives to help retain existing GPs in the workforce.

Beyond the obesity headlines

Also in the news was the Government’s latest strategy to tackle obesity, with headline grabbing initiatives, such as 'bicycles on prescription'.

Beyond the headlines, there were some interesting public health initiatives - a ban on advertising junk food before 9 pm, for example, which we support - and there were several plans that have implicati ons for general practice, but without much necessary detail. Primary care staff to be trained as healthy weight coaches, an NHS-endorsed weight loss app, and more online tools for people with obesity-related conditions, all sound worth exploring in principle - but we need to know how they would work in practice, and the College is asking these questions of Government.

Overall, we are pleased to see a strategy that aims to encourage and support our patients to make healthier life choices. It is, of course, what GPs and our teams already do, every day, where appropriate - and we’ve seen schemes, such as being able to refer patients to gym trials and weight loss clinics work well before. The College’s own Parkrun Practice scheme has been a great success.

However, we do need to be careful about medicalising exercise - it might sound trivial but we need to clearly distinguish between a recommendation and a prescription. It is perfectly legitimate to recommend to a patient that they take up cycling, or try the local parkrun, but we don’t want to get to a point where patients think they have to visit the GP before they can go on a bike ride or for a run.

10,000 aspiring medics register for Observe GP

The College’s Observe GP platform, part of our wider Discover GP initiative, has had more than 10,000 aspiring medics register to get a virtual taste of what it’s like working in general practice, since it launched just over three months ago.

Registrants can access a series of pre-recorded videos and take part in activities to gain an understanding of primary care, as they would during a traditional work experience placement in a GP surgery - something that hasn’t been possible during the COVID-19 lockdown.

What’s more, Observe GP has already been publicly endorsed by more than half of UK medical schools, and is mentioned by the Medical Schools Council as a suitable means of demonstrating work experience for those applying to medical school.

It’s so important to reach out to young people and let them know how diverse, rewarding and challenging a career in general practice can be. Thank you to Vice Chair Mike Holmes for leading this work, and all practices, GPs, practice staff and others who worked hard to develop this platform. A great achievement.

Vaccination guidance

Practices will now be busy adapting their plans to account for the expansion of the flu vaccination programme this winter. It’s a decision that the College has supported as a sensible precaution as we prepare for a potential second wave of COVID-19, but again (a theme in this week’s message) we need more detail. As a College we’re advising Public Health England on the practicalities, and we’ll keep you updated.

In the meantime, you can view our guidance on delivering a mass vaccination programme during the COVID-19 pandemic.

Post written by

Professor Martin Marshall, Chair of RCGP Council

Professor Martin Marshall is Chair of the Royal College of General Practitioners and a GP in Newham, East London. He is also Professor of Healthcare Improvement at UCL in the Department of Primary Care and Population Health. Previously he was Programme Director for Population Health and Primary Care at UCLPartners (2014-2019), Director of Research & Development at the Health Foundation (2007-2012), Deputy Chief Medical Officer for England and Director General in the Department of Health (2006-2007), Professor of General Practice at the University of Manchester (2000-2006) and a Harkness Fellow in Healthcare Policy. 

He is a Fellow of the Royal College of Physicians of London and of the Faculty of Public Health Medicine and was a non-executive director of the Care Quality Commission until 2012. He has advised governments in Singapore, Egypt, Canada and New Zealand, has over 230 publications in the field of quality improvement and health service redesign and his primary academic interest is in maximising the impact of research on practice. In 2005 he was awarded a CBE in the Queen’s Birthday Honours for Services to Health Care. 

A co-founder and driving force of the Rethinking Medicine movement, Martin has a passionate commitment to the values of the NHS, patient care and ensuring the GP voice is central in a time of great change. When he’s not working, he likes being outside, preferably on a mountain or a coastal path with his wife Sue and their puppy.

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