Another eventful meeting of RCGP Council – I am lucky enough to have been elected during very interesting times for our profession! Today’s meeting was very special and I am privileged to have played a part in today’s decision by Council to oppose Physician Associates working within General Practice. We did discuss a few other things too, believe it or not!
My husband John was speaking at a conference at BMA House today, so I had company on my trip to London! He was speaking at the sessional GPs’ conference; he gave a talk about how we have set up a private GP clinic which offers ethical, evidence-based care (as opposed to the screening factories and Kenalog-floggers which dominate the private sector currently…).
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C64 – Physician Associate guidance for GP practices that employ Physician Associates
This paper was marked as confidential, though the day before Council it was leaked on Twitter (I refuse to call it X 😂), which generated a lot of debate about the now-infamous “blue box” – a grandfather clause which, if passed, would have allowed PAs already working in GP to work beyond the scope of practice guidance if their GP supervisor thought they were competent to do so. Although I had grave concerns about the inclusion of the blue box, my concerns went further than that – the free text analysis of the membership consultation made it patently obvious that many GPs who responded to the consultation felt that there was no role for PAs in General Practice at all, and, when speaking to GPs on social media and in “real life”, that is a view I hear articulated again and again. So, when I spoke, I proposed an amendment. Here is how I spoke to this motion:
I was absolutely horrified to see the final paragraph of the scope of practice guidance. To my mind it makes a mockery of everything we have done thus far – we have gone to considerable trouble and expense to define very clearly a set of red lines and a scope of practice for PAs working in Primary Care. We have gone to the effort and expense of arranging a consultation of our membership to ask them what they think – and the consultation turned up some absolutely horrifying stories of patient safety being put at risk. Colleagues, if we approve the statement in the blue box, then quite frankly I think we will deserve every consequence which comes our way. And consequences will come – a backlash from our members, perhaps even no confidence votes and falling membership numbers. I would argue that we will have wasted our members’ funds if we disregard all the work we have done thus far. We are a charity as well as a membership organisation. Our charitable objective is: “To encourage, foster and maintain the highest possible standards in general medical practice”. We will not be doing that if we approve the statement in box 2. Colleagues, I beg you to vote no to vote 2, for the sake of the reputation of our College and for the sake of patient safety.
In respect of vote 1, I would like to put forward an amendment and I have a seconder for this. The sentence as it is has two parts which are confusing. I suggest we first vote on the sentence “PAs can have an enabling role in General Practice”, then proceed to a vote on the red lines after this. A significant number of our members feel that there is no role for PAs in General Practice as demonstrated by the responses on the survey. Yet we have not asked Council its position on whether the college should support PAs in general practice. This is about patient safety and to ensure we encourage, foster and maintain the highest possible standards in general medical practice.
Kamila, as Chair, suggested that we continue to hear other Council members’ views on the motion as it currently stood, then we would return to the question of my proposed amendment later on. As Council operates under the Chatham House rule, I can’t namecheck individuals, but overall I was really impressed by the calibre of debate and the extent to which Council reps had clearly listened to their electorate.
At the end of the initial discussion, Kamila moved to the question of my proposed amendment. She confirmed that, as it was an amendment rather than a motion, a seconder was not needed. It was at her discretion as Chair whether to allow the amendment, and to her great credit she agreed that we could indeed change the first part of the motion such that we would first vote on whether Council opposed the use of PAs in General Practice, and then we would only vote about whether to reaffirm the red lines if Council did not reject the use of PAs in General Practice.
Council voted to oppose the use of Physician Associates in General Practice – 61% of GPs voted in favour of my amendment – and so a further vote on our previously-agreed red lines did not take place; they still stand from the last time we voted on them.
Given that, despite RCGP’s stance, there will still be some PAs working in General Practice, Council did approve three sets of guidance to support GP practices which do currently employ PAs. These are going to be edited as a result of the discussions today, so they won’t be published for, probably, a few weeks – watch this space!
I am absolutely chuffed to have been a small part of the fightback against this threat to patient safety. I had a lot of help from other Council members, but I’m not sure what those people would be happy for me to say publicly, so I’ll leave them to identify themselves publicly if they choose to. As ever in this role, I am guided by the RCGP’s charitable objectives: “to encourage, foster and maintain the highest possible standards in general medical practice.” Today Council did exactly that.
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C65 – Post-election activity and policy asks
This paper wasn’t confidential, so if you’re a College member, do take a look at it in the members’ area of the website. Council members were very supportive of this paper overall. Several speakers praised the paper’s focus on “de-risking” GP partnership; many GPs are deterred from becoming partners because of very real concerns about unlimited liability, being personally bankrupted by being the “last man standing”, and onerous premises costs. There was also an interesting discussion about whether the inevitable direction of travel is that GP surgeries will get bigger – one partner at a small practice spoke passionately about the flexibility and responsiveness of smaller surgeries, and the fact that, for him, working in a small practice means he gets to know his patients better. Another Council member asked whether there is an evidence base to show whether working at scale actually improves outcomes. One Council member spoke movingly about the need to maintain the connection between patients and doctors, and keep alive the concept of “my doctor”.
I spoke as follows:
This is a great paper, and in particular I was pleased to see it spelled out that GPs are avoiding partnership not because they are lazy or selfish, but because the current contractual situation exposes GP partners to huge amounts of personal risk and liability. I think that the College should oppose any move to a fully salaried service – it is not what our members want, it would be incredibly expensive, and although it might paradoxically reduce the average GP’s workload, it would likely worsen the patient experience.
I absolutely endorse the suggestion in this paper that RCGP should support a mixed economy model, and that the College should call for action to address barriers to partnership, such as unlimited liability and the responsibility for premises ownership and maintenance.
Regarding discussion question 2, the enemy of continuity of care is urgent access – there is a need to be pragmatic and balance the two, with urgent care provided by whoever is available, and routine care delivered by the patient’s usual GP. If Wes Streeting wants to bring back the family doctor, he will need to stop berating us if we can’t see all non-urgent presentations same day. My personal experience suggests that it is very possible to deliver continuity of care and relationship-based care. We do this very well at our private practice. We offer continuity within a small team rather than guaranteeing it with one individual, though for non-urgent problems patients can choose to see the same doctor every time. We have half-hour appointments, so we can really build rapport with our patients – not achievable within the current NHS, but it would be a start if NHS GPs had the funding, premises and staffing to offer 15 or 20 minute GP appointments as the default. And one solution for delivering continuity in a profession dominated by part-time working is to buddy up and have small teams – so for example patients may not see the same GP every time, but they could see one of a small team of GPs every time. This system works very well in one NHS surgery I’m familiar with up in the north west – I’d be happy to try to put College staff in touch with the partners there if they want to use them as a case study.
C68 – Council forum options
This is a paper which probably won’t be of much interest to you unless you’re also on Council 😂 Essentially, we discussed potential ways in which Council members might be able to communicate formally between meetings. For informal discussions, we already have an unofficial Council WhatsApp group. The paper outlined various options, including the RCGP Member Forum and an official listserver, and then Council members made various other suggestions, including Signal and WhatsApp Communities. Further work will be done to take this forward. When I spoke on this item, I thanked the RCGP Council Members who administer the current informal group, Sonali Kinra and Victoria Tzortziou-Brown, for their hard work; and I suggested that we avoid moving across to the RCGP Members’ Forum to discuss Council business, because traffic and engagement is currently poor – having looked at it for the first time earlier this week, it appears to be used only by College Officers, RCGP staffers, and a handful of other enthusiasts.
C69a – Report to Council from Working Group on Preparations for the Possible Legalisation of Assisted Dying in one or more jurisdictions of the British Isles
For various reasons I didn’t end up speaking on this paper; and, although C69a is not confidential, there was a related paper, C69b, which was. For those reasons, I don’t plan to write about this discussion here.
C72 – Consolidated management report
Chris Askew gave us an update about his work as Chief Executive Officer of RCGP. I’ve got to say that I really like Chris and I think RCGP did well to recruit him to this role. He’s a really good manager – he welcomes questions and constructive challenge; he makes everyone feel listened to; and he is friendly and personable. I asked Chris a question during this section of the agenda; unfortunately there was a further outage during last week’s SCA. I facilitate half-day release teaching for GPST3s in Sefton and one of our local trainees was affected – she told me that she didn’t know what she was and wasn’t allowed to do in the immediate aftermath of the outage, and she was unsure if she was allowed to phone or email the RCGP exams team because technically she was still meant to be under exam conditions. I asked if the College could provide some kind of guidance for SCA candidates so they know what to do in the unfortunate event that there is an outage during their exam. Chris made it clear that this issue was already on the College’s radar and that it will be looked at.
C73 – Outcome of the 2024 Council elections and election report
I noted that turnout was very low, and that it seems to have been particularly low for the last few years; and I asked whether the move to online-only voting might have affected turnout and engagement. (Until a few years ago, RCGP members had the option to vote by post.) Chris promised to look into whether the drop in turnout had coincided with the removal of postal voting and will let me know.
C77 – Adopting the term GP Registrars
I had hoped to speak on this item, but time was limited – our PA debate earlier in the day had hugely overrun, so there was pressure for us to claw time back so people wouldn’t miss their trains – so I didn’t get chance. Happily, the motion passed with a resounding majority, and GP trainees will now be known as “GP registrars” rather than “Associates in Training” within RCGP. However, it is important to note that GP registrars will still be associate members, rather than full members, of the College. Anyway, I can’t wait to find out what “InnovAiT” journal ends up being renamed as – hopefully there’ll still be a pun in the title!
Conclusion
Due to efficient chairing from Kamila, we actually finished pretty much bang on time in the end! A few of us even had time for a post-Council drink before catching our trains home! Today was a wonderful day; I feel so privileged to have been in the room where such an important decision was made.
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I remain, as ever, your faithful servant; keep in touch!