We need activity-based funding and a more tightly defined contract for NHS general practices

In a letter published in the British Medical Journal, I respond to comments from Dr David Shepherd and Dr Hendrik Beerstecher about an editorial I wrote on shortages of general practitioners in the NHS. Dr Shepherd argues that capitation-based funding for general practice can work if the total amount of funding was increase and better methods were used to allocate funds to general practices. Dr Beerstecher argues that there is a mismatch between the supply of general practitioners and demand for their services.

In my response, I state that that increasing the amount of funding for primary care would be a step forward. Moving from the current Carr-Hill formula for allocating budgets to general practices to a formula with more patient level clinical data would also be helpful. But case mix adjusted formulas such as the Johns Hopkins adjusted clinical groups (ACG) system have limitations—particularly when used for smaller populations such as those covered by the typical NHS general practice.

Furthermore, an entirely capitation based formula would not prevent the shift of unfunded work from specialist care to primary care, which is one of the major problems currently facing general practices and one that clinical commissioning groups in England seem unwilling or unable to tackle.

I agree with Dr Beerstecher about the mismatch between the supply of GPs in the NHS and demands for their services. I allude to this when I state that GP services might need to be scaled back to fit the public funding available. Demands on GPs could be reduced if practices had a more tightly defined contract with the NHS.

The current GP contract is vague and open ended, setting few limits on the quantity or range of services that GPs are expected to offer the NHS and their patients. Furthermore, government policy in recent years has been to encourage GPs to offer even more services and make themselves more available to patients—for example, by requiring GPs to open their practice for longer hours without a substantial increase in the GP workforce. These policies have led to higher demands on primary care.

GPs are also faced with patients expecting them to fill gaps in local health services. For example, patients with dental problems often present (inappropriately) to their GPs because of problems accessing dental services. These are all problems that need to be tackled by NHS commissioners.

Dr Javier Salerno reflects on his experience of teaching medical students

Dr Javier Salerno won a 2017 Lifetime Teaching Award from the School of Public Health for his contribution to teaching medical students from Imperial College London on primary care attachments. Dr Salerno accepted his award by sharing some reflections of what students have said to him over the years.

I like this rotation as we do hands on medicine: it gives students the experience of seeing patients from very early days in their illness and the opportunity to see a lot of different patients. 

I learned more medicine in this practice than in hospitals. I did not have a clue what I was going to do as a post graduate studies however after this rotation I am considering general practice very seriously. I will read my BMJ, NEJM, Lancet, JAMA on a weekly basis! 

After diagnosing 3 melanomas on young people, they asked how did I find them if they had come for a flu like illness and chest infections. I asked them to remove their tops and melanomas were in rear dorsal areas and behind the arms. But why did you do that…..? Because of a 4 letter word which does not beginning with f (they did not have an idea of such word)…the word is CARE which they should also take as part of their education in medicine and humanity. 

You are not just a GP, are you? (Stated several times by medical students) You are a reader of medicine aren’t you (most flattering compliment to me)?

Dr Salerno comments that “My aims for medical students: to make it very interesting, to share enthusiasm and humanity, care and compassion, friendship, up-to-date knowledge and above all fun! This is what they taught me in my medical school: San Fernando medicine faculty/San Marcos University, Lima, Peru.

Lambeth CCG 2017 Award for Outstanding Contribution to Primary Care

I was very honoured to have won the 2017 Lambeth CCG Award for Outstanding Contribution to Primary Care. Lambeth CCG noted that “Dr Majeed has made a huge contribution to primary care research and teaching, as well as providing high quality kind care to his patients in Clapham, where he has worked as a GP for over 20 years. Dr Majeed was also recognised recently in Pulse magazine as one of the 50 most influential GPs in the UK.”

Imperial College GP Tutor Dr Christine Scott wins a 2017 Lifetime Teaching Award

Imperial College GP Tutor, Dr Christine Scott, won a 2017 Lifetime Teaching Award for her contribution to teaching medical students from Imperial College London. Here, she reflects on her experiences of teaching medical students.

Were you aware you were students’ inspiration and role model?
I think we often underestimate our impact on students. Now, as I read my feedback I recognise once again how extremely influential we are. What a great privilege, and what a great responsibility!

How long have you been teaching Imperial Medical Students for?
A lot of my embarrassment in receiving a lifetime teaching award is that I’ve only really been teaching at Imperial for about eight years. In a former era, I taught undergraduates from my alma mater, Newcastle University.

Why so long?
It hasn’t really been a very long time but I have been privileged to teach a number of different courses from first-year communication skills and First Clinical Attachment (FCA), doing some lecturing and teaching both in my practice and in the Department for Year 5 students on GP placement.

Why Imperial?
I really became involved in Imperial when I came along with a colleague to an introductory teaching session. It was a pragmatic decision, sessions were available and it’s my local medical school.

What kind of qualifications / CPD did you build up when teaching and how did this help you in this role?
Early on in my time teaching, I attended the Deanery Introduction to Teaching in Primary Care course (ITPCC). This really inspired me to be creative about the way I taught and gave me confidence to experiment, I really got a taste for it. Over the years, the annual GP teachers’ day and foundations of clinical practice (FoCP) conferences have been wonderful opportunities to learn. I always come not only with CPD credits but with my mind buzzing with new ideas of ways to teach and a whole new PDP for myself.

In what ways has teaching changed you and the way you practice medicine?
I think teaching has helped me to be more reflective and self-critical but also more confident. There is nothing like teaching something to ensure that you understand it well yourself and this is particularly true teaching within the clinical setting. My students have inspired me and challenged me to look at my practice through their young eyes. The skills of facilitation and feedback that I have learnt have had wider applicability working within the practice team. Lots of the teaching provided to us GP tutors at Imperial has also been extremely helpful. I look back gratefully on a number of memorable sessions, particularly those led by Giskin Day. Her teaching on medicine in the humanities has rekindled my love of reading and given me the courage to become creative!

Do you think hosting students has benefitted your GP practice, or the community you serve, in anyway?
The patients love talking to students and the perspective they bring, both on individual patients and on the service in general have been really useful. I think it also gives the whole practice a sense that they are contributing to the development of future doctors. In these days when we often feel tired and under pressure, it’s great to have the refreshing medical student perspective.

With the current NHS admin and recruitment pressures what would you be telling a family member if they were a GP and considering teaching?
Do it! The students you meet and the support and training you gain will be part of keeping you enthusiastic. When it works well, and it mostly does, the tutor-student partnership is formative for both parties, we change students but they change us. It is also clear from students that GPs are the people that really recognise them as individuals, adapt teaching to suit their learning needs and care about them – and that really counts. Finally, when I am old and unwell I want well taught and caring doctors to look after me!

Is there a memorable funny story from teaching you can imagine still recounting in the future?
I can’t really think of any funny stories, but certainly touching ones. The student who after his patient project was given a small silver teaspoon to remind him of parts of her story. My first year students performing a ballad to tell their patients story. Most recently two students explaining their patient’s illness using a wonderful model of a computer they had made as an allegory for his life.

We’ve heard about a beautiful house in France – tell us more about ‘life after being an Imperial teacher’
The beautiful house is on the edge of Paris and is part of my husband’s job. The main thing that will happen in my life after Imperial is being able to spend much more time in Paris with him making the most of all Paris offers. I’m also hoping to do some work developing appraisal with doctors working abroad and take some of my counselling skills to support our local church community. There will be plenty of time for coffee and museum visits and my Imperial friends will be warmly welcomed so keep in touch!

Should all GPs become NHS employees?

In a debate article in the BMJ, Laurence Buckman and I discuss the arguments for against GPs in England becoming NHS employees. Primary care in England’s NHS is in crisis. Recruitment of GPs is difficult throughout England, with many practices reporting vacant posts; many GPs are considering retiring early, and others want to cut down on their clinical work. The problems faced by GPs are partly due to the contracts that general practices have to provide NHS services and the way secondary care is organised. These contracts encourage the NHS to transfer work to primary care with the expectation that GPs will pick up this work at little or no extra cost. Most GPs would have no problem with taking on such work if they were given time to deal with it during their current working week. If GPs had employment contracts similar to NHS consultants they could have job plans, with time allocated for clinical work and for activities such as administration, teaching, training, and research.

Read the full article on the BMJ website.

GP Tutor Dr Dana Beale gives a view from the community

As part of our View from the Community series of articles, our Year 6 Specialty Choice Lead Dr Ros Herbert interviewed community teacher Dr Dana Beale, to get the inside track on what it’s like being a teacher for Imperial College.

Dana, tell me what first got you interested in homeless medicine?

Dr Dana Beale aboard her narrowboat

“Incredibly I was inspired by the same module I did as a student at Imperial College that I am now teaching on! Back then it was ‘medical and social care of the homeless’ and was based at the surgery for the homeless in Great Chapel Street – a fabulous service that showed me that primary care tailored to this vulnerable and challenging group existed and I promised myself there and then that I would return to work in this field.”

What makes you so enthusiastic about this work?

“I find this line of work a breath of fresh air; at times incredibly challenging but hugely rewarding. I feel privileged to be able to delve into patients’ lives at often their most chaotic and vulnerable, to reach out and essentially say ‘right…. How can we help you out here?’ I love the fact that it can range from helping those with complex medical cases and advanced pathology to psychiatric and psychological support with all sorts of things thrown in along the way. It feels natural to me to be faced with someone who needs an intense and complex team-based approach and to figure out where on earth to start – and to recognise that sometimes all that is needed is to show basic human kindness and just listen. The team around me makes my job a thousand times easier every day.”

What challenges does this “specialty” have?

“It can be a big challenge dealing with people who have often had difficult childhoods then have lost everything and are at rock bottom. Behaviour can be aggressive or defensive and it can be hard to strike the right balance between being approachable but also staying safe; between being supportive whilst also not acquiescing to every request – for example drug seeking behaviour. But over time I have learned how to help people to see that what they think they need RIGHT NOW may be the most detrimental thing to them in the long-run. We don’t always get it right and are always still learning. Risk management and good team communication is vital.”

If you were PM (not a bad idea?!) what would you do to improve the lot of the homeless?

“As PM I would make reducing health and wealth inequalities a key priority. I would seek to steer away from the perception that these are lazy people who want something for nothing and are just a drain on society. Epidemiological studies tell us that countries that support their unemployed and incapacitated will see a quicker and more sustained return to working life and being ‘productive’ in society – rather than focusing on ever more brutal sanctioning and impossible hoops to jump through.”

You obviously love teaching the students, tell us why?

“I feel honoured to be charged with fresh young minds to teach – so much of the time they really do teach me too! I like finding out about my students and which paths they hope to take and to perhaps plant a few seeds that will blossom in their later practice. Even if just one person looks at the homeless heroin addict they are dealing with in A+E, on the wards or in a GP surgery through a different filter and remembers that they are a human being with their own unique story, I feel I will have achieved something.”