Martin Marshall addresses RCGP Fresh Approach online conference
Publication date: 11 February 2021
Something’s happening in general practice that doesn’t happen often; we’re being openly and warmly praised for our efforts. Of course most of our patients are grateful for what we do but to be heaped with praise by the media and by so many politicians over our vaccination effort is, I have to say, slightly unnerving. This is particularly so after last summer’s open season when we were criticised for changing our model of delivering care in order to keep our patients safe.
Praise helps. Even though we are confident about our value to the NHS, what the media and politicians say about us matters because it feeds into our perceptions of self-worth and we know that self-worth underpins our job satisfaction and our effectiveness. It’s remarkable how selfless people are when they feel that what they’re doing, however tough, is valued by others. And not feeling valued is the most common reason cited by clinicians for low morale and burnout.
So I think we should bask, briefly, in the knowledge that people are celebrating the heroic efforts of GPs and our teams. We decided to take the lead in the vaccination programme despite our existing workload and the complexity of the challenge. We did so because it was the right thing to do for our patients and our communities and because we have experience of running mass vaccination programmes. And we did so because we wanted the job of protecting our most vulnerable patients done properly.
We were joined by thousands of GPs who came out of retirement to support their local communities and by many other health professional colleagues and volunteers.
Unsurprisingly GPs have been innovative and pragmatic - I've heard inspiring stories about GP colleagues calling in favours to source marquees and enlisting the help of their families and voluntary groups in order to get their local vaccine programme up and running.
The way in which you have rallied to the vaccination challenge has been incredible, especially when in tandem you’ve been keeping high priority normal GP services up and running and delivering the biggest-ever flu vaccine programme.
I hope you feel your College has supported you with these efforts. We have highlighted your concerns about supplies and have encouraged our governments to get as many vaccines as possible to the general practice vaccination centres – remarkably over 75% of the 13 million plus vaccines administered so far in the UK have been delivered by general practice. We lobbied successfully to reduce the pointless bureaucracy required to get retirees into the vaccination workforce. We championed the needs of our Black, Asian and minority ethnic communities and colleagues who have suffered so disproportionately from the pandemic.
We haven’t shied away from taking tough decisions, supporting the case for prioritisation and the delayed second doses made by the JCVI and our CMOs because we thought the decisions were on balance the right ones.
We’ve produced guidance for practices, learning materials and events and all of the officers have contributed to an unprecedented level of media coverage, using every opportunity to promote general practice.
Our contribution to the national vaccination effort has preoccupied us for several months and will do for months to come. Who knows what the future Covid vaccination programme will look like but I guess it’s likely that general practice will remain responsible for providing booster doses to our vulnerable patients, perhaps even in the same syringe as the annual flu jab.
And if that’s the case I guess we’ll add an expanded vaccination programme – highly effective interventions with one of the lowest Number Needed to Treat in medical practice – to the other transactional tasks that we do. By ‘transactional’ I’m referring to medical practice which is narrow in scope and time-limited – work which is at the other end of the spectrum from relational medical practice.
Transactional activities are important but relational practice is the essence of our work, our raison-d’etre as expert medical generalists. It feels to me that much of our work during the pandemic crisis has, by necessity, become more transactional and perhaps less patient-centred. Some would argue that the crisis has simply speeded up a trend which has made the practice of relationship-based care more challenging for many GPs over decades. This trend has been driven by rising workload, performance-managed contracts and the protocolisation of care, as well as by societal and demographic changes.
I think this trend should concern us and that’s why I established the reinvigoration of relationship-based care as one of our strategic priorities for the College. I want to tell you about this work and how it is progressing.
We all have stories about how the relationships that we build with our patients are an important part of our effectiveness as clinicians.
For the last 7 years I’ve looked after a patient who I will call Mohammed, a 40-year-old immigrant from Iran who was obese and had poorly controlled type 2 diabetes. I’d been seeing him for more than a year before he opened up to me about the reasons for his health problems. I learnt that he and his family lived in a grossly overcrowded apartment with no kitchen. He used to eat all of his meals in one of East London’s many fried chicken shops. Mohammed found the food enjoyable, cheap and filling and didn’t initially show much inclination to change his lifestyle. Over 2-3 years I worked with other members of our team and with social workers to get him rehoused, to join a job club, to start exercising in the local gym and to attend a cooking course with his wife. He confided to me that he wouldn’t have done any of this if I hadn’t suggested that he might benefit, if he hadn’t trusted me and if I hadn’t supported him. There have been ups and downs along the way and I’m not claiming any miracles, but 7 years down the line he’s in a much better place.
Some years ago in a challenging editorial Trish Greenhalgh asked readers to think about their experience as a patient, seeing their own GP. Did you like her, she asks? Did she welcome you? Did she listen to you and empathise with you? Did she remember what you’ve previously told her? Did she show interest in you and your family? Did she follow up on previous conversations? Did it feel like she is focused on your agenda rather than hers? Did she seem to have your best interests at heart? Trish said that if the answer to most or all of these questions is yes, you have a GP who is attempting to build a relationship with you because she believes that will make her a more effective clinician.
As GPs we’ve long-recognised the power of the so-called therapeutic relationship but it seems to me that we haven’t always been sufficiently explicit about just how important it is. Please excuse me getting all rhetorical but it feels to me that the relationship between a patient and their GP is as important as a scalpel is to a surgeon. If relationships were a drug, NICE and other guideline developers would have to mandate their use. But relationships, and the ways in which we build and utilize them, aren’t drugs, so we don’t talk about them very much. As a consequence there are many people who simply don’t understand how important relationships are and that’s why general practice is seen by others as an increasingly transactional medical specialty.
Of course some of the issues which patients bring to their GP are, reasonably, transactional in nature, uncomplicated chest infections, BP checks and of course the Covid vaccination programme, though even these activities can provide important opportunities to build personal relationships. It is difficult to identify how much of our work can reasonably be classified as transactional because it depends to an extent on an individual doctor’s inclination and practical ability to look beyond the presenting problem. But fundamentally general practice is a medical specialty which defines itself in person-centred and relationship-focused terms. Whilst some practices continue to deliver highly personalised care by maintaining personal lists, and others are exploring new approaches to delivering personal care for example using micro-teams, most practices are just struggling to enact what they were trained to do and something that they believe to be important.
And that’s why the College has long asserted that what was commonly called ‘pastoral care’ is core to the values of general practice and this is why over many years we’ve talked about related concepts such as continuity, the therapeutic relationship, empathy and person-centred care. I believe that the dilution or loss of the relational element of general practice would damage the quality of patient care, the efficiency of the NHS, and the specialty of general practice and that’s why it’s a priority for our College.
So, we’re scientists, committed to using the best available research evidence, so what is the evidence that relationships matter? Relationship based care is a term which encompasses a range of over-lapping concepts, some of which have a long-established theoretical and empirical basis supporting them. Most usually these include the concepts of continuity of care, the therapeutic relationship, empathy and person-centred care. Research in all of these areas, most of which is observational or case study-based, so not the most robust of designs, suggests that relationships are important. And the findings seem to be consistent over time and in different health systems.
We know that continuity is strongly associated with increased patient satisfaction and experience; increased compliance with medical advice; better health outcomes; and low mortality rates. We know that some patients value continuity more than others, and this varies according to the reasons they’re seeking healthcare. We also know that continuity leads to lower costs; lower use of EDs; reduced likelihood of being admitted to hospital; and higher GP job satisfaction. And we know that there are several instruments for routinely measuring continuity of care in practice.
We know from qualitative studies that key components of the therapeutic relationship include trust - a belief that a person’s words and actions are credible and can be relied upon - as well as commitment, receptivity and honesty. And we know that the ability to demonstrate empathy is a core component of the therapeutic relationship and that demonstrating empathy is associated with higher patient satisfaction, better adherence, reduced anxiety, better enablement and improved outcomes. The evidence tells us that patients want to know that clinicians are keen to engage emotionally: they look for clues to reassure themselves of their clinician’s desire to care. And we know that there is a robust neurobiological basis for empathy with distinct parts of the brain firing up when empathy is exhibited or perceived.
So there’s lots of established evidence that relationships seem to matter. But how relevant is this evidence in the context in which we are currently operating? What is the impact of remote consulting on relationship based care? This is an issue which is particularly pertinent for us now, as we start to explore the most appropriate post-Covid balance between face-to-face and remote consultations.
Some of the research about the use of telephones has been around for decades but new evidence about all forms of digital consultation is developing rapidly. The established literature tells us that telephone consultations tend to be shorter, cover fewer problems, are characterized by less data gathering, less advice, less rapport building and are perceived to be less safe than face to face ones. We also know that relationship building can be stronger by video than phone, possibly because doctors tend to give more attention by video and because of the benefits of seeing facial expressions. And interestingly, an RCT carried out recently in Hong Kong suggested that video consultations are more effective than face to face ones carried out when both parties are wearing masks. Rather relevant at the moment!
I think there are a number of important questions that we as a College need to address if we are to take relationship based medicine forward in a way which benefits patients and clinicians. I’m going to focus on 6 of those questions.
First, are relationships sufficiently important that they should be actively promoted and designed into future models of general practice? I think that the evidence-based benefits that I’ve outlined suggest that they should be, and that new policies impacting on general practice should be risk assessed to understand their impact on relationships.
Our challenge is to determine when relationships add sufficient value to ensure that their benefits are utilised, and when they don’t (for example, when a patient should be booked in with a doctor they know and when they can be booked with any clinician). We know that some people value continuity more than others (e.g. older people) and some health problems/conditions benefit from relationships more than others (e.g. those with multiple morbidities and some of those with mental health problems). One key practical step is to increase the length of non-triage GP consultations; the traditional 10-minute consultation is a major impediment to relationship based care, increasingly so as the complexity of presentations increases. This requires both a reduction in workload and different ways of working – these are other priorities for our College.
My second question is whether relationship-based care be delivered in the absence of continuity of care? The evidence is clear that knowing patients over time is an important element of relationship based care but should it be a defining one? A growing number of doctors, like me, work part time, many work as locums, and many are unable to work in the same practice for a long period of time. Whilst continuity of care should be encouraged, if it is framed as essential then there is a risk that a large proportion of the GP workforce will feel marginalized, will be made to feel like they’re not ‘proper’ GPs. But all doctors use their expertise in psychology and sociology to rapidly build trusting and empathetic relationships, perhaps even in a single consultation – speed-relationships, if you like. This begs new questions: are these speed-relationships less substantive and therefore less effective than ones built up over time? Even if they are, is the concept of a ‘relationship-light’ model a useful addition to the GP’s repertoire?
My third question is whether remote consultations are a threat to relationship-based care? I don’t think they are inevitably though the evidence I cited earlier does point to challenges. But established evidence, particularly evidence that is 20 plus years old, is not necessarily a predictor of the future. Are the kinds of telephone and video consultations that we’re conducting now during the Covid era different in nature (i.e. more substantive) from those evaluated in the past? Can we develop remote consulting skills to close the gap between the benefits of face-to-face consultations and remote ones? Can technology be used to encourage relationship-based care, in the ways we’re starting to observe in trainees video submissions for the MRCGP?
These are practical questions which beg rapid answers. If you thought that remote consultations were a necessary but temporary evil, think again. Last July, the Secretary of State, Matt Hancock, gave a speech at the Royal College of Physicians in which he said, ‘from now on, all consultations should be tele-consultations unless there’s a compelling clinical reason not to’.
As a College we don’t agree. We don’t want to turn the clock back, we know that remote consultations have a role to play in the emerging general practice landscape – some patients prefer them, and so do some GPs. But, if there’s one thing I’ve learnt during the course of the pandemic, it’s that it’s much harder to build a relationship with a patient, to establish trust and empathy, through a remote consultation. And without that personal connection, without knowing the person behind the symptoms, it’s harder for GPs to do our jobs.
My fourth question is whether relationship based care can be delivered as well in large practices and by multidisciplinary teams as in small practices and by small teams? The answer is yes and there’s no doubt in my mind that relationship-based care should not be the monopoly of GPs because many of our patients enjoy and benefit from their relationships with other members of our team. But we do know that the larger the team, the greater the risk that care becomes impersonal. And the means that relationships need to be actively designed into the new models of care. There are many examples of this happening across the country in a thoughtful way, including shared personal lists and multi-disciplinary micro-teams.
My fifth question is what can we do as a College to raise the profile of relationship-based care and persuade policy makers of its importance? Most GPs understand the importance of effective relationships and most patients value them most of the time. But policy makers and NHS leaders can be a challenging group to persuade of the benefits. Interestingly midwives seem to have persuaded policy makers that continuity for antenatal and intrapartum care is essential and leads to better outcomes but GPs haven’t yet managed to achieve this.
I think we need to talk about relationship based care more, highlight its importance using empirical evidence and case studies, and challenge examples of policies and practices which damage the formation of relationships. And I suspect we will be more effective in getting the message across if we speak the language of those we are trying to influence. Policy makers are focused on value – the best outcomes for the lowest cost. Research evidence shows that trusting relationships reduce unnecessary prescribing, investigations and referrals. In contrast, treating all presenting problems in a transactional way can be wasteful. Relationship based care is highly cost-effective; that’s the language that policy makers want to hear.
And my final question is how can we support clinicians to practice relationship based medicine to best effect? Most obviously, of course, we need time for what Victor Montori called ‘unhurried consultations’ and the College continues to work hard to reduce our workload.
I think we need to be more explicit that utilising the benefits of relationships are a core component of general practice and this needs to start at an undergraduate level in order to attract those doctors into our specialty who are as interested in people as they are in diseases. We need to ramp up teaching and training about relationship-based medicine in the specialist training curriculum, whilst at the same time recognising that some early career doctors may not see the full value of relationships until they have more consulting experience.
In particular, more training and support is required in remote consulting to support all of us to develop our skills in providing relationship-based care. The extent to which consulting face-to-face and remotely requires a different skill-set is increasingly recognized and there are some pointers which help us to focus on important educational areas. For example, we know that patients benefit from ‘preparation’ for all consultations and remote ones are no exception; digital access such as that using E-consult encourages patients to work through what they want and how to make best use of different options.
So, in summary, relationship-based care is a fundamental feature of effective general practice and I think that our ability as GPs to deliver it is at risk. And the less opportunity there is to utilize relationships, the less practitioners and patients experience it, the less it will be valued and the more it is at risk. So I think there is an urgency in our need to address the challenge.
We need to make it clear that there’s nothing soft about relationships and our interest in relationships isn’t yearning for a lost and never to be rediscovered past. Relationship based care is deliverable despite the many challenges we face.
I think that our College has a central role in promoting the benefits of relationship-based care and I really hope you will want to get involved in this work. Thanks for listening.
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Notes to editor
The Royal College of General Practitioners is a network of more than 52,000 family doctors working to improve care for patients. We work to encourage and maintain the highest standards of general medical practice and act as the voice of GPs on education, training, research and clinical standards.