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The Shrinking GP Workforce

Friday 7 July 2017

Much has been written about the worrying and potentially catastrophic decline in GP numbers over recent years, but have you noticed that some of your local colleagues appear to be wasting away before your very eyes? I’m talking biomass rather than body count here, and not only are their waistlines shrinking, but several of them have developed an almost cult-like zeal and ocular glint. It can be a little disarming. I’ve had to gently probe several colleagues recently to enquire whether they ought to be having further investigations, to be reassured that not only are they up to their eyes in pristine physical fettle, but mentally purring on all cylinders as well. So what's going on?

Low carbohydrate diets are what. Atkins and other high fat diets have been around for a while, but there is increasing evidence from around the globe that low carbohydrate diets can reverse Type 2 diabetes. We have local proponents and experts in our midst who have become internationally renowned for their knowledge and drive. Campbell Murdoch and Will Harris from Wells Health Centre, along with other colleagues incorporate the diet ideas into their holistic approach to Health and Wellbeing (Human Five), and the evidence is increasingly compelling both internationally and also with local success stories. So why are the dieticians still advising new diabetics about carbohydrates forming the basis of the diet? Much of the block appears to come from secondary care, where they will be seeing only the tippiest tip of the diabetes/impaired glucose tolerance fatberg. Primary Care is where the vast bulk (in every sense) of the problem presents, and if we’re serious about trying to significantly improve the health of a huge cohort of the population and reduce future health costs, where better to start?

The STP as a whole feels to be spending too much time and energy discussing organisational form and process, with precious little evidence that anything has changed, or is going to in the near future. The troops are overworked, disengaged, and most will plod into work on a Monday morning, happy to find the roof still on the premises, and get stuck in as they do every other Monday. Much is made of asking how to engage Primary care and get them to show some interest in the STP process, and our answer is always the same: tell them what will be different next Monday. We struggle to grasp the enormity and complexity of all the STP workstreams, and they all feel too remote and irrelevant to us at the moment. What we really need is something that could be driven from Primary Care, using local enthusiasts, something that would tick lots of STP boxes and spread as they start to gain traction and enthusiasm builds. Can you sense my drift floating within catchable reach?

Maybe start with a pilot- possibly aligned with SPQS or whatever quality improvement scheme happens to alight next year- properly funded and incentivised, driven locally and (importantly) from Primary Care with support from the other bits of the system. With the right leadership and motivation, ramped up by judicious use of social media, we could make a real difference for a significant number of our patients.

We wrote to practices recently to introduce Team GP (aka in respectable circles as the Somerset GP Board or SGPB), and there has never been a greater need for a solid voice for Primary care. There was a very modest proposal presented to the STP recently to fund the roll-out of Enhanced Primary Care across Somerset. This relates to the provision of health coaches to build on the model already up and running in some parts of the county, and involves the recruitment of non-clinicians to support certain patient groups in their practices. Not all practices might want to follow the model, but it was a well-worked and costed proposal, and had LMC support. Given that the pool of doctors, nurses, paramedics and pharmacists is drying up at an alarming rate, it makes sense to fish in somebody else’s pond. Considering this was a countywide proposal, the sums involved against the overall budget were peanutoid, and although there was support for the model, the additional funding was not agreed. However, at the same meeting a proposal for a scheme labelled “Discharge to Assess” was discussed and waved one step further down the pathway to adoption. As the title suggests, this involves getting patients out of the acute setting and then assessing what's their ongoing care needs might be. Inevitably and obviously, this will have a significant impact on community services, should there happen to be any, and there was no significant consideration or quantification of the effects on Primary Care (as was explicitly admitted in the paper). This is frankly ridiculous, and demonstrates how lopsided the STP process has become. Any transformation of the system requires funding, and without it nothing will change. Team GP isn’t going to need a motivational psychologist, although it might be quite fun to put in a business case to ask for one.

What we are going to need, however, are arrangements to discuss how the development of the SGPB will need to be reflected in our individual constitutions, how we are funded to attend meetings, how we tie in the expertise from other GPs involved in liaison roles with the Foundation Trusts or the COG, and much more besides. We are going to try and get as many as we can of our key GPs from across Somerset together in the next few weeks if possible- albeit holiday season- to thrash some things out.

I’m pleased to report that the Improved Access IT arrangements are working well in our neck of the woods. We had a phone call this week from a neighbouring practice to query why two of our patients were booked into their IA slots. Our receptionists were as surprised as theirs, especially as it turned out that the patients concerned had both died last week. It transpired that when our doctor had spoken to their doctor to discuss helping with the cremation certification, they’d somehow been given appointments. I’m not sure they’ll turn up.

It’s been a strange and disparate couple of weeks. It started at glorious Glastonbury; I’ve been to several Glastos in the past and never needed wellies, a record I was happy to extend. Caroline was working hard, but I was free to enjoy the show. One of the things I’ve missed in recent years is the cut and thrust of debate with drug reps, or at least some of them. Being a dispensing practice, they would often swarm round us, and on one particular Monday morning we had three ‘rentareps’ in the waiting room, each promoting omeprazole/losec, but for three different doses and indications. It was perhaps understandable then that I felt a familiar frisson of excitement to be approached in the Arcadia rave area at the festival late one night by a gentleman offering us an exciting product called MDMA. Curiously, he didn’t seem prepared to enter into any discussion about mode of action, bioavailability, contraindications, whether it was on the formulary, or even whether it interfered with bisoprolol. I don’t expect a logoed pen or sticky pads these days, but he hadn’t got any data sheets or PILs of any sort. Very odd.

I had to leave the festival early, and headed down to Bournemouth on Sunday afternoon, leaving Mrs. Chair craning to hear the Killers from behind a large policeman. I was off to the BMA Annual Representatives Meeting (ARM), which brings together all branches of the profession, including medical students and retired members. I was there as a representative from the LMC’s Conference, rather than a geographical area. There were some meaty debates, particularly one morning session that ended in a vote to support the decriminalisation of abortion. In the GP section, one of the old GPC lags, Peter Holden, made an impassioned rebuttal of the BMA leaders’ wishes to the contrary, potentially enabling practices to be able to declare ‘black alerts’. I was there for three out of the four days and left slightly early so that I could get back to Somerset for the CCG quarterly meeting in Bridgwater. This week I have mainly been playing Practice Manager, as the real one is currently sunning herself somewhere in the Canaries, and generally buffing the place up for the arrival of our gleaming new partner next week. Gleaming, that is, in much the same way as “The Flying Scotsman” gleams, our new partner being a mature and experienced model, used to steaming at speed, prone to wearing a kilt, and being called Rob.

Nick Bray

(T-8) It’s happening soon, people.

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