Heather’s notes from RCGP Council 22 June 2024

Another enjoyable Council meeting – my third as a Nationally Elected Council Member! This was probably the least eventful of the Council meetings I’ve attended, but I still have plenty to update you on.

Firstly, an apology: I realise I have been a little bit less responsive than usual of late. It probably isn’t wise for me to go into details at this stage, but essentially I have had a very unpleasant experience recently. I am being well supported by the police – and the BMA, who have been absolutely wonderful. My husband, and my parents, are being hugely supportive too. Please be kind if I am not quite my usual self for a while, or if I don’t respond immediately (or at all) when you contact me. I continue to do my best to represent you.

The Chair’s welcome – some highlights

  • Senior figures at the College are acutely aware of the GP jobs crisis and are lobbying stakeholders at every opportunity. Kamila suggested that Council members might wish to send her details of medical unemployment in their local area. If you have a story to share, please email me (heather.ryan@nhs.net) and I can collate your concerns and forward them to Kamila.
  • King Charles has been confirmed as the Royal Patron of RCGP, but don’t get too excited – he is Patron of around 700 organisations, so I don’t think he’ll be dropping into Council any time soon! However, I was pleased to hear that he is, reportedly, very positive about GPs.
  • Council Members’ declaration of interest forms will be published shortly and will be visible to the entire College membership. There are no current plans to redact special category data, but any Council member with concerns can contact Kamila to discuss further.

C43 – Preventive Medicine

This paper asked Council to support the adoption of “preventive medicine” as RCGP’s clinical policy priority for the next three years. Essentially, the paper proposes that the College should lobby for GPs to take a more prominent role in promoting a population-level approach to proactive care, rather than reactively waiting for patients to become ill then treating them. The paper advocates a focus on lifestyle modification to delay or prevent the onset of disease.

 The paper received a broadly positive reception, though several Council members argued that the College is likely to have a far greater impact if it lobbies for strategic political changes to address socioeconomic determinants of health, rather than focusing on lifestyle advice given by individual GPs to individual patients.

Although there was much in this paper I agreed with, whenever somebody talks about things that GPs are best placed to do, my inner sceptic always wonders what additional resource will be made available to us to facilitate that – or, if no funding is available, what GPs should stop doing to give them capacity to pick up this new work. I also had concerns about the risk of overdiagnosis. I spoke to the paper as follows:

Heather Ryan, Nationally Elected Member. Thank you for bringing this paper, Michael – I thought it was really thought-provoking. However I worry a little about how this will be received by the wider membership. This paper suggests that College should call for greater resourcing of General Practice, on the grounds that preventative work could be funded by this. I think we can only ask members to do more work if we get significant additional resource. At the moment, many of our members are struggling to meet the needs of patients who are already unwell, and if offered more funding, many would argue that it should be used to deal with patients presenting with illnesses. What work should we stop doing in order to make time for more preventive work? GP surgeries are pushed to the brink already – without significant additional funding and staffing, I cannot see how our members can make time to do yet more work, and I think they will feel we are out of touch if we say they should.

I was relieved to see the repeated references to “evidence-based” in this document, given that some aspects of primary prevention and early intervention are less well-evidenced than others. I do think it is vital that the College focus on high-value interventions, rather than interventions of dubious clinical impact. I raised an eyebrow at the mention of “aiming to slow down or eliminate the onset of conditions” – this is not always of clinical value, as some conditions have a long latent period, or may never cause clinically relevant disease. Has the overdiagnosis group had any input into this policy? If not, can this be added to the ‘internal activity’ planned for this policy? (As a declaration of interest, I subscribe to the overdiagnosis group mailing list.)

I note the British Society of Lifestyle Medicine is listed as a key stakeholder – although much of the BSLM’s approach is commendably evidence-based, some isn’t, such as their promotion of the UPF hypothesis, which most academic nutritionists agree is grossly oversimplified and not supported by the existing evidence. (As another declaration of interest, I sit on an advisory board for Nestle, but that does mean that I know what I am talking about.) I would respectfully ask that you engage with BSLM with caution and ensure that any policies that the College makes are supported by evidence rather than ideology.

C46 – Responding to the climate emergency

In many ways, papers C43 and C46 were diametrically opposed: while C43 seemed to be predicated on the assumption that more medicine is a good thing, C46 had a refreshing focus on the benefits of deprescribing. 

The background to this paper is that the climate emergency is one of RCGP’s four strategic priorities for 2023-2026, and this topic was first discussed at the November 2023 Council meeting, when the Officers received robust feedback to the effect that encouraging GPs to look after the planet might be perceived as inflammatory when they don’t currently have the resources to look after themselves, let alone their patients. At that meeting I suggested that the College should focus on promoting “win-win” initiatives which save practices time and/or money as well as helping the environment. 

It is a testament to the Officer team that they took this feedback on board and presented a fantastic, pragmatic paper this time around. Despite this, when we discussed the current paper at our Faculty Board meeting on Wednesday, further concerns were raised about the need for sensitive messaging about GP workload. I articulated those concerns today:

This is a fantastic paper, Victoria, thank you, and it is a great testament to your leadership that you have clearly taken heed of the feedback you got when this was last discussed at November Council. I was thrilled to see the focus on reducing overprescribing and prioritising high-value care. I was also pleased to see how pragmatic many of the suggestions are – many suggestions would also reduce either cost or GP workload, for example the suggestion that electronic prescribing should be rolled out in those areas of the UK that do not yet have it. I was shocked by the statistic in the paper that approximately 15% of hospital admissions in over-65s are caused by the adverse effects of medication, and I think that makes the case beautifully that too much medicine can be bad for patients as well as the planet.

I would just like to sound a note of caution about how this policy is communicated to our members. I’m a Nationally Elected Member, but I attend Faculty Board. When we discussed this paper at Faculty Board, it was suggested by others that debate about climate change risks alienating members and making us seem out of touch, given the more immediate crises facing General Practice. As I say, I think this is a very clever paper because most of the suggestions would reduce cost or workload or both – I think we just need to be careful about the messaging.

Other Council members articulated similar concerns about how GPs might respond to any suggestion that College cares more about the green agenda than it does about its members. The Officers’ closing remarks made it clear that, although Council was broadly supportive of this paper, they had heard and understood those concerns and would ensure that the excellent ideas in this paper are communicated sensitively to our membership.

Verbal update from the Chair on the PA policy statement and consultation

This was a fast-moving and complex discussion, so forgive me if any errors have crept into this account; if so, let me know and I will of course correct them.

If you’re politically active enough to be reading a blog about an RCGP Council meeting, you have no doubt already seen the results of the RCGP member consultation about Physician Associates in General Practice, following which the College called for a halt to the recruitment of PAs into Primary Care for the time being. There was widespread praise for our bold stance, and although a couple of Council members expressed a desire for a more conciliatory stance towards Physician Associates, the vast majority of Council members wholeheartedly endorsed the College’s current position.

The next step is that the Officers will engage with external stakeholders, including patient groups and indeed PAs themselves. They will also, of course, consult with College members. A further paper will be brought to Council in September 2024 concerning the scope of practice, induction, and supervision of PAs working in General Practice.

Some other notes:

  • There was some discussion about who will regulate PAs. Since March 2024 Council, RCGP’s position is that an organisation other than the GMC should have this responsibility. This remains the College’s position. The Officer team indicated that, unfortunately, the most likely outcome is that the GMC will indeed be the regulator, despite the College’s concerns. However, other Council members pointed out that there is a potential legal challenge to the GMC as regulator of PAs – at least one organisation intends to launch a legal challenge. Watch this space!
  • The Royal College of Physicians has reportedly indicated that they will no longer take responsibility for writing papers about PAs working in specialties other than their own.
  • The College continues to campaign for urgent action to grow the GP workforce, including advocating that ARRS funding should be opened up to GPs. Current rumours suggest that the rules may at some point change such that ARRS funding can be used to employ GPs if those GPs are being employed to supervise ARRS staff. (My personal view is that the neatest solution would be to abolish ARRS and pour that money into core GP funding, but it seems that would be far too simple for the politicians!)
  • One Council member very kindly thanked me by name for my role in pushing for the PA member consultation. That same person made a very interesting suggestion – that the College should repeat the PA member consultation after the RCGP scope of practice document has been released, to see if the guidance is being followed and if PAs are working more safely as a result. I think this is a fab idea – after all, in clinical practice we would re-audit as part of the audit cycle! If PAs aren’t working safely even once the guidance has been released, I think that would add weight to the idea that the PA role is ill-suited to General Practice…
  • Various members, including me, called for a halt to the utilisation and/or training of PAs in General Practice full stop. One member argued very articulately that most patients have “no idea” about the PA role and do not understand how little training and knowledge PAs have. I thought that was an excellent point. If patients don’t understand the PA role, how can they give informed consent to be treated by one?
  • In contrast, one Council member argued that we should not “get on our high horses about patient safety” because GPs make mistakes too. Personally, I disagree – if even professionals with at least 10 years of training (5 years of medical school and 5 years of postgraduate training) make mistakes, surely allowing people with just 2 years of training to see complex patients is a recipe for disaster?
  • One Council member pointed out the inherent confusion created by referring to GP trainees as “Associates in Training”. How can we expect patients to understand that Physician Associates are not doctors if we call our own trainee doctors Associates? The Officers reassured us that this is already being addressed within the College, and our trainee colleagues will increasingly be referred to as GP Registrars rather than AiTs. This is very welcome news.
  • In light of events at RCP, various commentators on social media have asked how likely Kamila is to be subject to a vote of no confidence. I don’t think that is going to happen, for two reasons. Firstly, procedurally, as far as I can tell from having read the Byelaws of RCGP, there is no mechanism by which “ordinary members” (i.e. non-Council members) can call for a vote of no confidence in an Officer. If I understand the rules correctly, a vote of no confidence cannot be triggered unless ten or more Council members request one. More than half of Council members need to vote in favour of the no confidence motion in order for it to succeed. It was clear during the meeting that Kamila has the confidence of a majority of RCGP Council, so I cannot imagine that a vote of no confidence would succeed at the present time even if it was brought.

I spoke on the PA discussion as follows:

Heather Ryan, nationally elected member. I am glad that the College has demonstrated leadership on this issue, and has showed real courage in taking on the political establishment in defence of patients. We have set a fantastic example to the other Medical Royal Colleges. However, in the 48 hours since our statement was released, I have been contacted by members asking why, given the damning findings of the consultation, we have not gone further. Given that we have called for a halt to the recruitment of new Physician Associates due to safety concerns, is the next step to think the unthinkable and call for the phasing out of all Physician Associates in Primary Care, given the inherent unsuitability of the PA role for the GP setting? And should the College call for a pause on the training of Physician Associate students full stop, given uncertainty on the future of the role? I am disappointed to hear you say just now that you do not plan to call for GPs to stop training PAs in primary care.

One RCGP member approached me while the survey was live to express their view that there was pro-PA bias in the survey design; they felt that the questions were asked from the starting point that PAs have a role to play in General Practice. This member felt that they had to heavily utilise the free-text boxes in order to express their view that PAs have no place at all in Primary Care. Who designed the survey and was the possibility of bias considered? You mentioned a Task and Finish group – who was on it and how were they chosen?

In terms of transparency, it is commendable that we have published a full report into the consultation findings, but many members have asked me for more detail about what the free text responses said – I understand that individual responses may need to be redacted for confidentiality reasons, but can we please publish more thematic analysis of the free text comments?

I agree that it is vital that this debate remains civil, but I do not feel we should be weaponising rhetoric about kindness in order to stifle debate about patient safety.

The response to my points was as follows:

  • Thematic analysis of the free-text comments on the survey will be published soon.
  • Some people have said that the survey was framed in an anti-PA way, and some feel it was pro-PA.
  • The Task & Finish group was assembled by invitation.
  • Although a few Council members have argued that RCGP should have gone further, there are no current plans to do so – the next step is to await the scope of practice document. However, in the meantime, we were reminded that it is up to individual GP practices whether they hire PAs. That is a good point – perhaps, as a profession, we just need to collectively stop employing PAs? But due to the way that General Practice is currently being funded in part via ARRS, that may not be as simple as it sounds.

C49 – Member motion

This was a motion advocating that the GP trainee representatives on Council should be able to vote at RCGP General Meetings, which currently they cannot. There was overwhelming support for this motion and it passed. However, due to the need for this to be officially approved by the Privy Council, it will apparently take 2-3 years to come into effect.

C50 – Governance Review Update

The paper itself is a bit dry (and I say this as a governance enthusiast!), but we were treated to a slideshow which explained the issues very well. We were told that this would be made more widely available, so watch this space. Essentially the issue is that our current structure is unwieldy, and it is sometimes unclear who is ultimately responsible for decision-making. There will be an all-member workshop on 11th September to discuss the Governance Review in more detail. I have to say how impressed I am by the reflection that is taking place within the College following the concerns raised at November’s AGM.

Conclusion


I think I’ve covered everything! If you have any questions or comments, please get in touch; as a Nationally Elected Council Member, my job is to represent the views of my electorate! If you’d be interested in attending a Council meeting as an observer, please let me know and I can put you in touch with the relevant people at the College. If you’re in Merseyside and Cheshire, I can arrange for you to observe a local Faculty Board meeting too! Have a lovely summer and stay in touch 🌞

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