Doing the right thing

8 April 2022

So much of what I learnt during my undergraduate training is long forgotten but one bit of wisdom stuck in my consciousness. It was a general physician (remember them?) who on every ward round reminded his students that 70 percent of the diagnosis is made by taking a detailed history, 25 percent by examining the patient and 5 percent by carrying out investigations. He’d never allow his team to order a test without a full inquisition as to how it would add value.

Over the years I frequently repeated this pearl to our trainees but it’s some time since I’ve done so with confidence. The turning point was when a bright young doctor challenged what I suspect she regarded as my old-fashioned practice. The history-examination-investigation balance should, she asserted, be 50:20:30. And, she added, it’s okay to order tests before you speak to or see the patient.

I disagree with her figures but I understand where she’s coming from. The practice of medicine is changing. Investigations reveal important findings that even a good history and examination can’t. We now know that our confidence in the predictive value of many of the physical signs we carefully elicited in our final exams was, well, misplaced.

But we also know that acting on the results of scans and blood tests can lead to significant harm for patients and often wastes precious resources – hence the profile of the over-diagnosis and too-much -medicine movements over the last couple of decades. 

So, I do carry out a higher proportion of investigations than I used to but I still see my role as protecting patients from the unintended consequences of interventionalist medicine. I think I’m doing the right thing but I also feel like I’m swimming against the tide. 

Latest updates from your College

Workforce planning amendment lives on

Despite MPs making the shameful decision to vote down the workforce planning amendment to the Health and Care Bill last week, I was very pleased that there was still appetite amongst members of the House of Lords to push on this further. 

In response to government feedback on the wording of the amendment, Conservative peer Baroness Cumberledge tabled a tweaked version, Amendment 29B (more information here), which was voted on in the Lords on Tuesday evening. The amendment passed with 187 peers for and 151 against and so it will now be voted on by MPs, for the third time, when the Bill returns to the House of Commons later this month.

In a week where the Health and Social Care Select Committee’s report into cancer services found that the biggest barrier to improvement is the size of the workforce delivering cancer care, this issue must not be ignored.

I’ll be reaching out to you in the next week or so to request that you once again email your MP to support this amendment that is so important for the future of our NHS. 

RCGP in the media

I appeared live on the BBC’s flagship political programme Newsnight (watch at 23:23) to discuss the Health and Social Care Select Committee’s report on cancer services. I talked about the unprecedented workload and workforce pressures GPs, our teams and colleagues across the NHS are working under, the impact this has on patients, and what decision-makers need to do to address it.

This was also the theme of an op-ed I wrote in the Independent, which made the case that falling satisfaction with the NHS is indicative of a service under pressure and that investing in general practice, and taking pledges to boost the GP workforce seriously, are vital moving forward. 

I was also interviewed on the BBC’s Today Programme (listen at 13:40) on Saturday morning, expressing some important public health messages about Covid vaccines for 5-11 year olds to coincide with booking for this patient cohort opening.

My comments about the importance of GP referrals for children and young people being taken seriously appeared in The Guardian.

‘Conversion therapy’ ban: A disappointing decision

I was disappointed by the Government saying it will ban so-called conversion therapy for gay and bisexual people in England and Wales – but not for trans people. 

The College is a long-standing signatory to a memorandum of understanding, along with around 20 other health organisations, opposing conversion therapy in the UK. Our resolve has not changed, and this shaped our response to the Government’s consultation

When this document was initially drawn up, it did only cover sexual orientation. When it was updated to include gender identity, some members did raise concerns as to what the definition of conversion therapy was and what the implications of this would be in practice. We worked with other signatories to ensure the document was clear that being opposed to conversion therapy did not mean opposing appropriate clinical interventions for trans and gender-questioning people (see point 6). This work has demonstrated that it is entirely possible to deliver a ban on conversion therapy that protects all LGBT people. It is critical that the Government come to this same position.

Caring for veterans on Falklands War anniversary

As the horror of the war in Ukraine continues, and we mark the 40th anniversary of the Falklands War, evidence has shown such events have the potential to trigger difficult thoughts and feelings for veterans.

At times like this the importance of our veteran friendly practice scheme is all too clear.

Surgeries may wish to actively promote their commitment to veterans and their involvement in the College initiative. 

An example message could read: “[Name of surgery] is aware that, with the 40th anniversary of the Falklands War and recent events in Ukraine, these events may have had an impact upon the health of some military veterans registered with us.  If you feel that it would be helpful to discuss any concerns, please do come forward and speak with one of our clinicians. The clinical lead for the surgery is [Name].”

BJGP research survey

The editorial team at the BJGP would like to hear your thoughts on how the dissemination of primary care research could be improved to better meet the needs of practising GPs and GP trainees.

If you’re a GP or GP trainee in the UK, we’d be grateful if you could complete this short survey.

DWP change to fit note – from 6th April 2022

On 6 April DWP changed regulations so that fit notes do not require a signature in ink to authorise them. Instead, a new template is being delivered that is authorised by the name of the doctor being included in the form. This means fit notes can be completed, authorised and sent digitally from 6 April.

This change does not otherwise alter the purpose and function of the fit note. GP IT systems are being updated over the coming weeks to support the change. While this is being rolled out the existing fit note will still be legally valid and should be accepted. The new guidance can be read here.

UKHSA issues alert over hepatitis rise

The UK Heath Security Agency has issued an alert to highlight that there has been an unusual increase in children under 10 with signs of hepatitis. There are approximately 60 cases that are currently being investigated to determine if there is a connection and what the underlying cause may be. It is too early to make any conclusions, but please do be vigilant with children presenting with the following symptoms and consider early referral for blood tests and further investigations.  It is possible that we will see an increase in children presenting to us due to media coverage. 

As you know, symptoms commonly associated with hepatitis, that parents are being asked to monitor and seek help for, include: dark urine; pale, grey-coloured poo; itchy skin; yellowing of the eyes and skin (jaundice); muscle and joint pain; a high temperature; feeling and being sick; feeling unusually tired all the time; loss of appetite; tummy pain.


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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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