Pulse reports that:

“GP negotiators expect every practice in the country to join a federation and help manage swathes of the NHS budget after throwing their weight behind the Government’s planned overhaul of GP commissioning.” 

The Royal Colege of General Practitioners developed and promoted the idea of GP ‘federations’ following the publication of its ‘road map’ for primary care in 2008. In an information paper from August 2008 it set out some of the key requirements for federations, which would include ‘a patient engagement strategy’. But there was little detail on what this should entail.

In backing this federation concept both the RCGP and the BMA are accepting the likely end of the single-handed GP practice. This was foreshadowed in the Darzi review’s strategy for primary and community care.

So we now have a future model, albeit with variants, which the government and GP leaders support, which will see all GPs gradually moving into joint enterprises that control probaby around 60% of the budget and commissioning for the NHS in England.

To whom will they be accountable? How will we know that their decisions to change services are in line with patients’ needs and expressed wishes?

All eyes are now on the government’s planned White Paper for further details of how it expects this model to be implemented. Mightydredd will be looking to see how the health secretary expects these clusters to engage with patients and the public.

Prof Steve Field (image http://thepointofkairos.blogspot.com)

The RCGP Chairman, Professor Steve Field, has a little known blog over at The Point of Kairos. It seems to be used to publish the Chairman’s e-letter update rather than anything more personal. However, it is a great step in the right direction as the Chairman blog used to be tucked away in the member’s area of the RCGP site. It is far more credible to have it available publicly and to their credit they have also allowed full comments with no moderation.

It hasn’t attracted a great deal of comment so far but the most recent post on revalidation has certainly elicited some fiercer criticism.

…as a GP Trainer, College Member and full time GP it is quite clear to me that revalidation has lost its way, fundamentally because it was never clear what it was for in the first place.

I cannot agree with your interpretation that it is time to gird up and carry on regardless.

This foolish process must stop

This is comfortably one of the more polite comments. I don’t agree with the ad hominem attacks as I do think Steve Field is in a tight spot with revalidation. Unlike many commenters I’m happy to support the principle of revalidation but I have plenty of concerns over the process.

The rather good blog name, The Point of Kairos, refers to a chapter in Neighbour’s, The Inner Apprentice, and comes from the Greek word kairos meaning the ‘right time for action, when events cry out to be taken in hand’. It feels like the current plans are struggling to win the argument with many GPs or politicians and we are indeed approaching the Point of Kairos for revalidation. Whether anyone can seize the moment remains to be seen.

Revalidation is being postponed. Again.

The current plans for revalidation of GPs hinge around appraisal. In medical education terms appraisal is fundamentally a formative process used to support and encourage development and foster lifelong learning. Slowly, but surely, the proposed revalidation model has been bolting bits on to appraisal in a bid to create a tool to ensure GP competence – so called ‘strengthened’ appraisal. The risk is they that create a monster, a ‘Frankenstein’ appraisal, unloved and unhelpful at picking out poor performance.

It’s worth pausing and considering what the basic function of revalidation should be. I suspect people want to know their GP is competent. They want their GP to know their stuff and they want them to treat them with some common decency. Now it is perhaps debatable about whether there was ever any genuine public concern about these areas but that is now beside the point. The mission is to reassure the public that that is indeed the case.

We are already awash with patient satisfaction surveys allegedly measuring if GPs are treating their patients as they wish. There is little need to expand on this. The best way to assess competence is almost certainly an examination. They are reliable, valid and fair. The enormous and undeniable advantage is that they are applicable to any GP in any unique branch of general practice. It won’t matter if you are a locum, prison doctor or GP principal the examination is equally valid and accessible. I would also suggest they meet Margaret McCartney’s sensible suggestion that they are evidence-based. They are relatively cheap but the real expense will come in scrutinising and supporting those who don’t pass whatever the chosen method. However, no system will be cheap.

Perhaps, and this is a big perhaps, the new government is blanching at the prospect of bankrolling a revalidation project that will currently do little to guarantee GP competence. The long grass beckons.

Dr Mahibur Rahman.

The MRCGP Applied Knowledge Test (AKT) examination has recently been made harder – the pass standard was increased after the January 2010 exam, leading to the lowest pass rate so far – 73% passed the exam in January (compared to a long term average of 79% passing).  The secret to passing the exam is effective preparation.

Here are some revision tips to help you pass the exam:

1. Plan your preparation – to cover the syllabus for this exam while also working will take most doctors 2-3 months revision.  Make sure you allow enough time to cover everything properly.
2. Remember the boring stuff – registrars tend to do less well at the organisational and evidence interpretation questions than in the clinical medicine questions.  These areas include questions on statistics, types of study, interpreting graphs and charts, practice management, medico legal issues, DVLA guidelines and certification.  20% of the marks come from these areas, and although they may be boring to study, they offer relatively easy marks.
3. Break your revision into bite sized chunks – after about an hour, your concentration and recall drops dramatically, so you will retain more by revising in multiple short sessions with breaks in between rather than a few longer sessions.
4. Focus on your weak areas – doctors often enjoy attempting questions on topics they are good at, as they feel good when they get a high score.  You should avoid this and instead spend more time in areas that you are NOT so confident on; as these are the subjects you are more likely to lose marks in.
5. Mix reading with practice – a good way to cement your learning and be sure that you can apply what you have read is to do a mixture of reading around core topics and practice sample AKT questions.  Ideally you should practice questions to time, as the pace in the real exam is very fast – you have to answer around 200 questions in 3 hours – this is less than 1 minute for each question!

The AKT is a challenging examination, but it is also fair.  Hopefully these tips will help you on your way to a pass.  Remember – if you fail to prepare, you should prepare to fail!

Dr Mahibur Rahman is the medical director of Emedica.  He is a portfolio GP and a consultant in Medical Education.  He has taught extensively on MRCGP and GP careers courses, as well as teaching GP trainers.  Details of the Emedica AKT Preparation course are available at http://courses.emedica.co.uk/acatalog/nMRCGP_AKT_Preparation.html

Emedica Alumni are entitled to a £20 discount – use this code when booking – alumniakt2010

1. Latest CV, copies of qualifications and Practice Leaflets (top 2 where are worked most often).
2. Old & new appraisal statements/PDP.
3. Evidence of Team Meetings = copies of Chambers Meeting Agenda, Minutes of meeting from PLOG.
4. Significant Events- Personal atleast 1 , Team – Copy of Siginificant Event discussions from PLOG (most PMC events are discussed in all chambers so they can be used).
5. Evidence of Learning- PMC speaker Meetings, Online Learning (doctors.net Certs , eGP).eGP has been launched by RCGP & is fantastic and whole learning experience is via virtual surgery…check it out…Also if you wish to be a writer for any of the modules there’s an online form that you can fill in & they’ll contact you back. eGP is also linked to eportfolio so whatever modules are done get registered automatically on the portfolio.
6. Case reviews- atleast 2 per year.
7. Pallant Appraisal package- list of all surgeries ,feedback from practices.
8. 360 feedback- RCGP forms (Personally done at a surgery where I work more often).
9. Patient Satisfaction Questionnaire -RCGP website (at the same surgery).
10. Evidence of involvement in Audit- Pallant sore throat Audit. Also my Appraiser accepted an audit that I did in 2008 /9 as Registrar.
11. Specialist Referral Feedback (from Pallant website)-couldn’t do this on time though!
12. Miscellaneous- cards, appreciation letters etc. For revalidation purposes all GPs will need 50 learning credits per year .1 hr learning = 1 credit. And we all know that any learning points that have been revisited or reviewed or discussed will count more. As an evidence for that my appraiser suggested keeping a learning diary at all times and share learning points.

He was very impressed by Pallant Medical! Richard my appraiser was surprised that PMC doesn’t have any Chambers in Crawley, Horsham area. He thought it would work very well! You might wish to think about it

Please feel free to add comments/advice re appraisals.

Cheers , Pallavi

John Pike, NASGP blogger

 John Pike, NASGP blogger

I was concerned by several aspects of the Learning Credits system described in this article in “GP” today.

My concerns are:

1.       We all have different learning styles that suit us. Personally, I enjoy using a very wide range of media for learning, but there are many who do not find courses helpful and others who do not benefit from internet learning. These preferred learning styles need to be respected.

2.       Personally, I find the limits on the number of annual credits GPs can claim from more basic training too restrictive and inflexible. I would prefer to see a more flexible scheme where appraisers check that the balance of learning is reasonable and appropriate to the doctor’s preferred learning styles.

3.       The article states that “Workplace learning is so important that the RCGP gives no upper limit”. This puts the country’s estimated 15,000 locums and other non-practice based doctors at a very considerable disadvantage compared to practice-based doctors. It is very difficult for locums to demonstrate workplace learning, other than PUNs and DENs. We are not able to make changes to practice systems as a result of learning. All we can hope to achieve is to give examples of patients for whom we acted differently as a result of a learning activity. I entirely agree with Richard (Fieldhouse)’s comment in the article that “locums will only be able to show impact ‘with difficulty’ because of their short-term contact with patients”.

My concerns are not for lack of trying myself. I now spend virtually my whole time on work, meetings, learning, preparing for appraisal and other work-related activities, such as commenting on documents or news items. I am just finalising my appraisal documentation for this year and note that I have spent 262 hours over the year across the following activities: courses, internet learning, mentoring group meetings, meetings of my clinical governance group, meetings of Bristol Association of Sessional Doctors, RCGP Severn Faculty Board meetings, doing an audit, practical sessions at the hospital for the DFSRH qualification, commenting on documents and other activities agreed for my PDP. This may seem excessive but it soon adds up when one tries to meet the requirements as they emerge and to respond to learning needs as one identifies them.

One of the key stated aims of revalidation was to improve quality of patient care. However, I am not alone in finding that the workload for appraisal and revalidation is now increasing so much that considerable extra stress is being generated. The point will come where this extra stress, far from improving quality of care, will actually have an adverse effect on it.

There has been some anxiety about clinical audit in revalidation for peripatetic locum GPs. However, NASGP recently agreed with Professor Mike Pringle (RCGP lead on revalidation) that prospective audits are acceptable. Simply decide what you will audit, collect data on patients as you see them and then enter the data onto a spreadsheet or Word document when you find time. When you have 10 or more patients, you can summarise the findings (you can tabulate these automatically if you use spreadsheet software) and then start on the second set of data collection. I recently became aware of a few prospective audits that you can do on the web at: http://www.guideline-audit.com. The site has a separate section for sessional GPs. I signed up for the chest infection and asthma exacerbation audits and entered data on the first 3 chest infection patients today. I asked permission from a partner yesterday to do the audit on patients in that particular practice and to print off my consultation records, which I have since shredded after entering data. I got a bit of a shock when I first saw the 5-part data entry form but, in reality, it did not take long to enter the data for each patient. The time was well worth it, since I was immediately able to view tables comparing my performance with other practices globally and the learning has already begun. I will really enjoy doing this audit.

Although I am not sure of the outcome yet of my membership by Assessment of Performance for the RCGP (iMap), the process did seem fair but there is a definite lack of understanding of the environment within which locums work.

For example, in the section on referral letters, one of the questions was “how would I ensure that the practice had followed up on an action that came back in a referral letter”, that I only obtained because I specifically went back to the practice to seek it out.

As salaried, locums and out of hours GPs are here to stay, there needs to be a whole competency framework around these positions agreed with the RCGP although I am concerned that the RCGP may not have representatives in significant numbers from these areas of practice, if at all. The competencies of these GPs are very different from the competencies of a good partner, and to try to judge them by these standards means they will fall short, and also not be tested on important areas of their practice, such as handing over cases, dealing with patients in a one off consultation, notes appropriate to the one-off consultation, negotiating a safe working environment, seeking feedback and working as part of a team in the locum, salaried or out of hours doctor environment.

Dr Christine Haseler

revalidation 2.0 this way please

Anything these days with a version number “2.0″ seems to suggests a web-savvy new-wave platform-oriented touchy-googly open-source hyphenated (!) idea. Not quite a description we should give to the latest Revalidation Guide from the RCGP (more like 1.5) but it certainly represents a shift in the right direction, with the college clearly having listened to GPs and acknowledgement of work still needed to do. There’s a rather enticing mention too of a planned website giving worked examples of audit for locums.

TOYS have been banned from Scots doctors’ waiting rooms because of fears they could spread the deadly swine flu bug.

Crèches at private family clinics in South Queensferry and Dalkeith have been cleared after the drastic move.

Magazines have also been swiped from the waiting rooms, replaced by signs explaining that the virus, which has killed four people in Scotland, can live on hard surfaces for over an hour.

But the doctors are on a collision course with the NHS after sources revealed they are against the toy ban, saying it simply raises public fears over the H1N1 virus.

Banning toys “makes sense” according to Dr Dean Marshall, chair of the British Medical Association’s Scottish GP committee.
His surgery, Dalkeith Medical Practice, in Midlothian, has banned all toys in a bid to stop infection spreading.

He said: “Our job is not to provide entertainment for children.

“Whether or not that makes us killjoys, I don’t know.

“But the first thing a child does when they see a toy is handle it or put it in their mouth, which how disease can spread.

“To be honest though I’m not aware of any evidence of anyone getting swine flu off a soft toy but the risk is there and it’s basic hygiene.”

Extremely ill patients

Leaving toys out would leave ill patients “at even more risk” according to Christine Stebbings, practice manager of South Queensferry Medical Practice.

She said: “We have some extremely ill patients coming in daily who would suffer if they caught the virus, so the decision to remove toys has been taken with them in mind.

“I don’t see how it could be seen as controversial. In fact we have a swine flu committee which meets weekly and makes pro-active decisions such as this for the best interests of our patients.

“The feedback we have had from them has been that they appreciate the fact that we are trying to minimise the risk of infection.”

The NHS sat on the fence on the issue, insisting they have not issued any advice to GPs either way.

Their hands are tied as the vast majority of Scotland’s GPs are not directly employed by the NHS and do not have to take orders from them

But an insider said senior policy makers were “surprised” at the action being taken by doctors.

The source said: “Banning toys has raised eyebrows among the doctors I’ve spoken to, because it could come across as scaremongering.

“Quite frankly the NHS has no power to make GPs do anything we say, so it means some places will do it and others won’t.

“Mixed messages about anything to do with swine flu are the last thing the government wants.”

“Bureaucracy gone mad”

A private firm in England, TPCT, banned toys from waiting rooms last November – almost half a year before the swine flu pandemic broke out.

At the time, doctors slammed the move as “bureaucracy gone mad.”

Dr Kailas Chand said: “Waiting rooms without toys must be a nightmare It is bureaucracy gone mad.

“We have introduced more toys at my surgery. If having toys means children don’t mind coming to see the doctor, they are definitely a good thing.”

Banning toys has the support of the Royal College of General Practitioners in Scotland, Dr Ken Lawton.

His group meets weekly with the Scottish Government to discuss ways to tackle Influenza A H1N1.

He said: “I am not aware of other practices doing this, however, a practice may feel after risk assessment that this is a proportionate response.

“Good hygiene is of course, essential.”

A Scottish Government spokesman said: “Individual GP surgeries are responsible for maintaining good hygiene standards in their waiting areas, including ensuring toys and magazines are kept clean, in accordance with guidance from the Scottish Government and professional organisations such as the RCGP.

“We have not issued any guidance instructing surgeries to remove such items and would consider any infection risk to be very low if cleanliness standards are maintained.”

We’re inviting our members to contribute to this evolving document which cab be downloaded from our main website. Here’s the executive summary:

• A patient satisfaction survey giving timely feedback to the doctor should be helpful for his personal reflection and for discussion at appraisal, but
• Patient-satisfaction surveys and MSF tools are not sufficiently robust for revalidation
• Neither of the two patient satisfaction tools currently used for the Quality and Outcomes Framework (QOF) has been formally assessed for reliability and their validation has been sub-optimal
• Currently used Patient Satisfaction Surveys and MSF are subjective and subject to huge elements of bias and to many variables outside the doctor’s control
• They are therefore unethical
• Some studies have shown no benefit, and even adverse results, from the use of MSFs
• A large study of a patient satisfaction survey used in Australia showed that it did not help GPs to improve patient-satisfaction over a nine year period
• Any tool used must be useful to GPs, helping GPs to improve their practice
• Any tool used must be acceptable to all GPs using it and GPs must have confidence in it
• Qualitative feedback is an essential part of any survey but commercial companies are not qualified to interpret it
• Qualitative feedback should be given to the GP at the end of each day for his own personal reflection and for later discussion at appraisal
• The GP concerned (perhaps with help from an appraisal discussion) is the only person qualified to interpret, and to reflect on, the results of Patient-Satisfaction Surveys and of MSF regarding himself.
• Different tools may be needed for regular members of a practice and for locum GPs

What strikes me is that locum audit is a chink in the RCGP’s armour and I remain surprised that the RCGP has never done any work to look at this issue.

It also exposes the absence of any investment – any investment – by the college in anything to do with working as a locum GP. Bearing In mind that at any one time 25% of all GPs (25% of all RCGP members?) are currently locum GPs, I’m sure that you’ll agree with us that this may make the college look a little bit slow off the mark. The common, and very strong, consensus from locums is that audit for locum GPs is on the spectrum somewhere between ‘pointless’ and ‘impossible’. If one even begins to scratch the surface of this issue, it starts to raise ugly questions and the RCGP needs to confront this, and move away from its current stance which is no less than burying its head in the sand.

Although laudable asking locums for ‘imaginative’ examples of audit, you and I know this will never happen, and I really think that it is unfair that you’re asking 15,000 individual locums to do this – it’s the college’s responsibility, and it is neglecting locums in their hour of need.

Although I respect the RCGP’s work on generic issues relating to general practice as a whole, it must represent all its proprietary constituents too – it is, after all, the Royal College of General Practitioners, and not General Practice.

All very well, and we need to accept the challenge. But of course we also need to accept that to be in any way realistic this is going to require substantial funding for development and implementation and so NASGP will now need to work with the RCGP to see how our Royal College is going to implement it’s first EVER work for it’s thousands of locum GP members.

When I asked myself how many practices I’d worked in last year I guessed around 15, although a proper look at my invoices showed I’d actually worked in 34 and I suspect that others too will have underestimated to a similar degree. So what, we may ask? As John Pike points out in our main article, revalidation in its current guise will expect every locum to provide two audits and two formal multisource feedbacks over the 5 year cycle. Unfortunately, there is not yet any evidence to show that GPs working in more than one practice a year can provide audit or MSF, let alone whether it’s useful or not.

If our best guestimate of there being 15,000 practicing locum GPs in the UK is any where near true, we’re talking here of around 8,000 GPs having to struggle to provide evidence for revalidation. That clearly is not only going to create a huge problem for a significant number of jobbing GPs, but also risks undermining the efforts of the RCGP whose task it is to ensure that it represents all GPs when clearly its ‘GP MOT’ revalidation will discriminate against many non-practice based GPs.

Predictably, I am not the only one. The NASGP have been running a little survey of their sessional GPs. While I wouldn’t like to speculate on the biases involved in a survey like this I feel it makes a valid point.

Usual story. The RCGP provides some speculative further information in their flu pandemic guidance.

4.10 Locum GPs

4.10.1 It is envisaged that PCOS will act as the employer for all available freelance locum GPs during a flu pandemic. This will preserve their indemnity at a time when they will be working at maximum flexibility, possibly moving frequently between practices.

4.10.2 Like all GPs, locum doctors need to be on a performers’ list relevant to the country in which they plan to work. As part of the preparation for a flu pandemic, PCOs must check their databases ensuring that they are robust and that data on them are correct, including contact details and email addresses.

4.10.3 Locums/freelance GPs must be included in any preparation and training programmes, including information ascades, and be issued with any necessary photo ID cards as provided to other frontline doctors.

4.10.4 It is envisaged that PCOs will contract to employ ALL available locum GPs for the duration of the pandemic so that they have indemnity protection and death-in-service benefits. The rate of pay and details of the employment arrangements are the subject of ongoing discussions at national level.

It is a little disturbing that it might take a pandemic for section 4.10.2 and 4.10.3 to happen. This seems like the kind of good practice that should happen all the time.

So us locum types may end up employed by the PCT. God help us. Personally, I hadn’t given any consideration whatsoever to the personal financial impact of a pandemic. However, it seems that some GPs are bearing it in mind. I heard from a colleague today that some practices have not been slow to contact the PCT to establish the additional payments they will receive in the event of a pandemic. The RCGP have thoughtfully provided some basic information at Appendix 1 (before the WHO pandemic alert levels and children dosages) of their document.

The Department of Health does not intend any general practice to be disadvantaged financially by its participation in responding to an influenza pandemic.

Is it really necessary to bother the PCT at this early stage about financial compensation? I am sure some GPs will be quick to offer the ‘We Are Running A Business” defence and I can understand that a full-blown pandemic could damage a business.  It will damage every single business in the UK. The effect on the economy of a full pandemic will be horrendous and it is likely that one of the few businesses that will receive economic protection from the government will be general practices.

It just makes me a little sad inside.

Phew.

That’s about the best way to sum up my general feelings about the current process. Pulse report in a mildy speculative fashion that:

A battle is also raging behind the scenes over how high to set the bar, with ministers placing the RCGP under strong pressure to agree to tougher procedures.

It’s difficult to know what they mean by ‘tougher procedures’ and I wouldn’t trust this government as far as I could kick Ed’s Balls. But they may have a point and this might be related to the fact we haven’t really set a ‘bar’. A trumped-up formative assessment used primarily for developmental purposes doesn’t really constitute a ‘bar’ at all. If I may mix some metaphors: it’s a hoop, not a bar. It will be very interesting to see what ‘tougher measures’ are being considered.

The whole thing is in a dismal state and I am surprised that there seems to be so little noise about this across the blogosphere. Thanks to this swine flu thingy, in medical terms, I would suggest it could be a good week to bury this news and there will little debate about revalidation. Depending on your perspective, delaying revalidation could be interpreted as being good or bad news but it’s difficult to imagine Liam Donaldson is spending much time worrying about revalidation this week.

Most GPs will be thrilled it is being put off. I’m thrilled too, not because of the complete lack of PCT resources to implement it, but mainly for the reason that the proposed revalidation looked so horribly flawed.

Pulse reports on the concerns of one GP about revalidation. The concern is specifically addressing the new process for measuring how much continuous professional development (CPD) a GP does in a year. GPs will score their CPD activities on the basis of how ‘challenging’ they are and how much ‘impact’ they have. The magic (and completely arbitrary) total is 50 units per year. The RCGP’s document on revalidation is now available and gives all the lurid details.

Why are we going through this process? Prof Field suggests:

There are significant numbers of GPs who are not actively learning and acquiring new knowledge and skills – we need to encourage them to.

Significant numbers? Is passively learning new skills and knowledge acceptable? Of course, one could argue that if there is a single GP out there who is not updating their skills that is significant. It could be very significant if you are the patient on the receiving end. Presumably Prof Field wouldn’t make a statement inferring real concern about a large number of GPs without evidence. I haven’t personally seen the evidence that there is a ‘significant’ issue within the profession.

As an appraiser, I have also been involved with the piloting of the new scheme, and there are a number of aspects to it that I quite like. It is relatively easy to incorporate into an appraisal and it is not hugely intrusive. It seeks to add an extra dimension to the measurement of ongoing education. It rewards educational practice that is more challenging to achieve and that changes the way care is delivered to patients. All very laudable.

But there are questions. Lots of them. How well does the amount of CPD you undertake correlate with your clinical competence? It may demonstrate enthusiasm for the subject but in no way does it measure how well you treat the patients. Perhaps it will encourage GPs to develop their clinical services in line with new thinking. Is there any evidence that this was an area in which practices were failing to deliver? And how does that help with the revalidation of individuals? Does completing a single measly audit per year infer competence? Dr Spinks raises the issue of how consistently appraisers will score the activities. Inter-rater reliability I think they call that. That is why there is a pilot and the only issue I have with this is that it doesn’t feel much like a pilot. It feels like a done deal. It is ‘Evidence Area 6′ of the RCGP’s document. It has been decided this is what we are going to do and we all have to toe the line. Prof Field quoted in Pulse again:

He said it was vital for GPs to get the system right to avoid a less favourable alternative being imposed.

This feels like a veiled threat. But a threat of what? Let’s consider something – if I were a member of the public and I felt GPs should be regulated I would want to know, with a certain amount of confidence, that they are competent.  Not how keen they are on CPD (the credits), or how much their patients like them (patient satisfaction questionnaires), or even how much their colleagues like and respect them (multi-source feedback).  What we need is a reliable, valid, consistent measure of a GP’s competence. Is it just me but isn’t that the definition of an examination?

A huge amount of time and effort is going into reinventing the wheel.

Medical students still have examinations because it is the single best way to prove competence. We already have a set of examinations that test GP competence – nMRCGP. It involves an Applied Knowledge Test and then a Clinical Skills Assessment. These can test skills across a wide range of competencies. Communication skills, problem-solving abilities and even some factual knowledge can all be assessed. Trainees also do a Workplace Based Assessment which involves all the woollier things like multi-source feedback and patient satisfaction questionnaires. GPs can (and already do) incorporate these elements into their annual appraisal.

If we are serious about ensuring GPs are competent the way forward is an annual appraisal and a 5 yearly examination. Everything else will be open to accusations of poor validity and reliability. It would also be a completely inclusive package. There would be no issues with sessional GPs, locums and GPs with special interests having difficulties meeting practice-based criteria.

I suspect examinations remain utterly unpalatable to many GPs. Perhaps some GPs will head for the exits at any sign of a revalidation examination. Ultimately, the majority of GPs are conscientious and competent, so revalidation remains a bitter pill to swallow.

I am well aware that the foremost GP bloggers, The Jobbing Doctor and Dr Crippen, are not salaried doctors. They are GP principals, partners in their businesses and I would venture to predict that both JD and JC will not be terribly thrilled at the prospect of a fully salaried profession. So, are they dinosaurs that deserve to go the way of the, er, dinosaurs?

There has always been something of a hierarchy with GPs. My hairdresser thinks that the real proper doctors are partners, then come salaried doctors then come locums at the bottom. I smile politely; she is the one with the scissors. This is not a particularly helpful viewpoint as each group brings appropriate qualities to the workforce. The issue seems to be that these differences are getting magnified and distorted.

Scotland is thinking about a salaried profession. There is a clear concern about a so-called two tier profession. My own post in January (GPs that wind me up – No 8) touched on this issue.

8. Practices that employ salaried GPs and nurse practitioners when what they really need is another partner.

This is primary care on the cheap and is often primarily motivated by the profit share for the existing partners. This pill is often sugared to ease the conscience (for the more sensitive souls) with mealy-mouthed excuses about skill mix. This letter agrees.

We could be more honest as a profession – few patients realise that GP surgeries are run as businesses for the profit of the partners. Maybe that’s why GP principals are kicking up a fuss?

If GP principals pursue this policy then the endpoint will be a fully salaried GP profession. Of course, it probably won’t be in the current GPs’ working life so why should they care?

GP principals have, for all the protestations, been shrinking their numbers. The proportion of salaried GPs has risen from 12% in 2005 to 33% in 2007. The RCGP’s Dr Clare Gerada:

Young GPs who feel ‘the ladder being pulled up’ as they are denied partnerships may defect to the private sector. The report points to ‘evidence that some private employers offer better terms and conditions’ than traditional general practices.

Now this may be for the simple reason that the practices fear for their survival in difficult times if they do not protect their interests. However, a common line is the ‘not me guv’nor’ defence. It reminds me of dog-walkers. It’s never their dog that has crapped on the pavement. It is always someone else’s dog.

Do I think that GP practices should be killed off as (semi) independent entities?  There are serious problems with a salaried workforce – there is a lot of stability built into a system where GPs are financially and emotionally invested in the community. This stability then leads to the holy grail of good continuity of care. This is an incredibly precious commodity that is difficult to quantify; it’s not tangible and it will resist QOF quality markers. However, we all know when we have experienced it.  If you have ever had a problem that needed more than 2-3 visits to the GP you will quickly come to appreciate it.

The Future

The more I consider the future the more I am happy with my three rules of general practice that I posted last September. In fact, I am considering elevating these to the loftier status of Laws. Maybe they could be eponymously named? It would make a fine alliteration.

Law 1. Every person in the UK is entitled to care from a named GP.

And they have to have reasonable access to that GP. As I said then: one patient, one genuinely responsible GP.

Law 2. The ‘named GP’ should have a maximum number of patients on their list.

This protects against larger polyclinic rubbish as well as the current situation where principals are forced into squeezing their own little workforces.

Law 3. The ‘named GP’ must retain a measure of control over how that clinical care is delivered.

Does the current system deliver on these Laws? Well, largely yes, but it is running into problems because it is squeezing Law 2 for economical reasons (government driven) and Law 3 with top-down targets and directives (government driven).

Would a fully salaried workforce do any better? I am not convinced that a salaried profession can deliver on any of these essentials. There is a danger of losing your named GP and there may be more mobility of GPs within the workforce with little control over numbers of patients. I find it highly improbable that a salaried workforce will gain control over the delivery of clinical care and it is more likely that more and more care will be pushed toward ‘cheaper’ alternatives. And before anyone hollers, I do not think that is because patients will become massively empowered instead. It is far more likely that there will be distant management from private companies delivering minimal care of government specified targets.

The current model of GP partnerships needs some tweaking. I’m happy to be salaried (A Positive Choice) and I don’t feel any sour grapes about partnership.  For all its faults I suspect it is a good mechanism for delivering personal primary care.

Rather than bowing to the external pressures with a fully salaried GP workforce maybe what we really need now is a Save the Dinosaur campaign.