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M A GA ZI NE O F TH E R CGP  I SSU E 19  A U TU MN 2 021

COLLEGE ACTS ON WORKFORCE CRISIS AND MEDIA ONSLAUGHT

1 | CONTENTS

CONTENTS 03 | NEWS 04

Big Interview – Professor Chris Whitty

RCGP rescue package for general practice

The great GP vaccination effort

New faces in Scotland and Wales

COLLEGE FIGHTS BACK TO DEFEND HARDWORKING GPS

13 | COLLEGE UPDATES 13

GPs’; mentoring programme on target for antibiotic prescribing

100 modules of online learning

By Martin Marshall

17 | OPINION 17

Green GPs talk climate change

21 | STORIES FROM THE 21

FRONTLINE

Gurkha welfare, the social media medic and the GP collective

24 | GP PIONEERS 24

The inspirational women who made general practice

13 15 Staff editors: Daniel Openshaw, Gillian Watson

Reporters: Amy Boreham; Lisa Boyle; Emily Brewer; Tanisha Dadar; Cian Daly; Lizzie Edwards; Nicolas Webb; Emma Wilkinson Cover cartoon: Martin Rowson

Inside cartoon: Kipper Williams Design: Aura Creative Ltd

Feedback: can be emailed to gpfrontline@rcgp.org.uk or tweeted using #gpfrontline. You can also write to us at GP Frontline, 30 Euston Square, London, NW1 2FB

2 | CONTENTS

ou can’t fail to have noticed that the profession has been in the full glare of media scrutiny for quite a while now. From tabloid to broadsheet, radio to television, nationally and regionally, critical articles detailing the ‘negative experiences’ faced by patients when trying to get face to face GP appointments have been everywhere. There’ve been numerous times in the past when GPs have unwittingly become the target of media criticism, but the recent onslaught is the worst I can remember in over 30 years of being a GP. All this vitriol for following government guidelines and trying to keep patients, and our practice teams, safe. As well as being offensive and inaccurate, it is also irresponsible as it poisons the relationship that GPs have with their patients and undermines the trust and confidence they have in us. You need to be pretty thick-skinned to be a GP, but these almost daily attacks on our professionalism, commitment and integrity are demoralising and wear you down. Some colleagues have described it as a ‘war of attrition’ and, after 18 months on the frontline of a pandemic, they simply haven’t got the energy to fight back. Nor do demoralised and exhausted GPs have the luxury of newspaper columns where they can vent. These sustained and unwarranted attacks have sent the College into full-on rebuttal mode and we are waging a daily battle to robustly challenge the succession of anti-GP stories. We have adopted stronger language in our media statements and are creating an ongoing narrative on our website and on social media to show what we are doing to defend the profession. Despite the negative tone of the coverage, our statements are getting a good showing in all the nationals – including, rather ironically, the Daily Mail which launched a whole frontpage campaign on the issue but still made one of our responses its ‘letter of the day’. We’ve had a good track record of having our

statements and letters printed, refuting the outrageous claims made by its columnists. Our response to one particularly malicious invective received nearly 1000 ‘likes’ on Twitter – as did our riposte to Jacob Rees-Mogg's divisive and untrue comments in the House of Commons. Thanks also to those members who have written their own letters and contacted their local TV and radio stations to put across their very powerful side of the story. The College Officers are also making time to appear on more ‘populist’ broadcast such as Good Morning Britain and regional TV stations to get our messages across to patients. I have appeared on both Radio 4’s Today and PM programmes and recently featured in an ITV Tonight programme highlighting the pressures that GPs are under. I need to emphasise that not all sections of the media have waded into the affray – some titles and journalists have actually been very supportive of general practice. The trade press have picked up on the action we are taking to fight back against the criticism and Pulse and GPonline have both featured positive stories on how the College and BMA are taking the media to task. I have also had robust opinion pieces printed in the Daily Express, Daily Mirror, Independent, HSJ and BMJ looking at the impact of media criticism on GP morale and the serious consequences this could have. Of course, whatever we say and however hard we work will never be enough to combat or outweigh the sheer force of negativity currently coming our way – and unfortunately, the patients who have benefited from remote consultations or seen their GP face to face during the pandemic are not telling the media about it. Tempting as it is to come out ‘all guns blazing’, we must remain measured and must always be seen as the patients’ advocate if we are to get the public, press and politicians back on side.

However, that does not stop us being incensed by the reprehensible allegations being levelled against us. As well as being described as ‘lazy’, ‘idle’ and denying patients appointments so that we can ‘play golf’, we have been accused of not giving our patients the same level of care that vets give to animals and of ‘costing lives’ by seeing patients remotely. While journalists and columnists are portraying themselves as the patients’ champion, they need to realise that these relentless attacks can have a much deeper impact. They can demoralise GPs to the point that they dread going to work or hasten their decision to leave the profession. At the other end of the scale, medical students are put off from choosing general practice – with serious consequences for patient care in the future – and those who do, often find themselves being denigrated and treated as ‘lesser’ medics by their peers. The real issue is that we are now seeing the fallout of over a decade of under investment in our service. Successive governments have allowed GP numbers to fall while volume

and complexity of patient demand has risen and continues to do so. GPs have long been criticised for working ‘part time’ when, in reality and as we all know, the job of a modern GP to provide safe, effective and personalised care for patients is becoming increasingly undoable. The solution is for the four governments of the UK to invest in general practice, including thousands more GPs and members of the wider practice team. We also need initiatives to reduce unnecessary bureaucracy for existing GPs to prevent burnout or their leaving the profession. The College will continue to challenge unfair criticism of hardworking GPs in the media and elsewhere – and continue our calls on governments to support general practice so that GPs can give patients the safe care they need. But the media should also play its part by showing more responsibility and campaigning for general practice, rather than denigrating hardworking GPs for trying to do their jobs in very difficult circumstances. 

NEWS

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B IG I N T ER VI EW

IN THE EYE OF THE STORM

ngland’s Chief Medical Officer, Professor Chris Whitty, has just rushed back to his office at the Department of Health and Social Care from unplanned, urgent meetings in Whitehall, down the road. It’s the day the Joint Committee on Vaccination and Immunisation has said the evidence isn’t clear on Covid-19 vaccinations for 12–15 year olds and has deferred to the four Chief Medical Officers of the UK for a view to inform what will be ultimately be a political decision by Government. He’s clearly an incredibly busy man – as he has been throughout as the clinical lead, and face, of the Covid-19 pandemic – but he’s making time for a rare sit-down interview with GP Frontline. The key message he wants to get across: “a massive thanks to general practitioners and the wider primary care team for what they’ve done during the pandemic and will have to continue to do over what will be a very difficult winter.” Prof Whitty sees taking a view on ‘difficult issues’ as a key part of the role. However, he is also clear that his role is to advise – and the Government’s role to make decisions. “My job is to be a doctor,” he explains, “it is right that people should ask me, and people like me, questions you would ask a doctor – and I may take advice from others, including GPs, before answering. Some decisions are highly technical, and it would be rare for a political leader to go against my advice on these, because it’s a medical question; but questions about what to do in terms of societal impact and economic interventions are for political leaders to take the call.” His first Government role was in 2009 when he joined the Department for International Development as Chief Scientific Adviser, a role he took on at the DHSC in 2016 – with responsibilities including leading the National Institute for Health Research – until becoming CMO in 2019, succeeding Prof Dame Sally Davies. He's a Consultant Physician at UCLH, Professor of Public Health at the London School of Hygiene and Tropical Medicine and Gresham Professor of Physic. An epidemiologist by specialty, he understands the importance of medical generalism with one of his priorities on becoming CMO to

04 | BIG INTERVIEW

promote a greater focus on generalism in medicine in order to care for the increasing numbers of people living with multiple, chronic conditions: “Medicine has been extraordinarily effective through medical science in dealing with individual diseases, and much less strong in dealing with people who’ve got multiple morbidities…I’d like to see a celebration of generalism that allows specialists to continue specialising, but maintaining the generalist skills that allow them to see, for example, an eight-year-old with six or seven conditions and that those interact, not just medically but in how that patient lives their life. “It’s what most GPs deal with all the time and it’s something I think the rest of the medical profession could learn a lot from,” he says. His priorities were obviously thrown into disarray in early 2020 with the onset of the Covid-19 pandemic. It made him one of the most recognisable faces in the country, taking part in regular press conferences alongside the Prime Minister, Cabinet Ministers and other scientific advisers. “It was the bit of the role I was least looking forward to,” he admits, “I had no idea that it would be as extensive as it is, but you’ve got to accept it if you take a role like this and then there’s an emergency. It’s the job of a doctor to communicate risk, and values, in an honest way.” In terms of how he’s dealt with the unprecedented scrutiny he modestly says; “not to get too obsessed with either the good or the bad. The best bit of advice I was given early in my career was never to worry about criticism from people you wouldn’t take advice from, and I’ve stuck to that.” As an epidemiologist with a clinical interest in infectious disease and experience of previous pandemics, Prof Whitty says he was ‘relatively familiar’ with the necessary areas of science to lead the pandemic response but insists there was no such thing as a ‘perfect’ person for the role. “We’re all shades of imperfect on this,” he says, “it was a new infection, there was a huge amount we didn’t know. You have the things you know, and a bunch of stuff you don’t, and you have to go with your best judgement. It’s the problem of dealing with uncertainty – something every GP has to deal with every day in their professional life.”

Department of Health and Social Care

Professor Chris Whitty reflects on his role leading the response to the biggest health crisis for a century. He speaks to Daniel Openshaw...

“A massive thanks to general practitioners and the wider primary care team for what they’ve done during the pandemic and will have to continue to do over what will be a very difficult winter.”

Casting his mind back to when he first heard about Covid-19, he says: “A lot of epidemics happen…very few of them turn into a pandemic. Back in early January last year our view was that things could go one of several ways. It could be something that’s locally contained, as MERS was in South Korea; it could be something that had regional impact with some spillover, such as we saw with SARS; or it could be something that went globally. That last option was less likely than the others on day one. “But as time went by, the more benign possibilities came off the table. A global pandemic was always a possibility but it became clearer and clearer this is what would happen. The nearest template we had – a very inexact one – was the 1918 flu pandemic. What that told us is that when these things start running, the impact on society as well as directly on health, is very significant.” Acknowledging stark differences, it is something Prof Whitty saw working on the HIV/AIDS pandemic, which he describes as a ‘formative experience’ in how he’s thought about medicine since. “In the UK it was a problem largely confined to particular populations, but in southern Africa where I was working around 30% of people my own age had HIV and there were no drugs available, and so they were going to die. It was really catastrophic. It was a very different pandemic to Covid, but you saw the extraordinary impact it had on society.” Now, his outlook is optimistic although he is very clear the pandemic ‘has a long way to run’ and that it’s ‘going to be bumpy’. He explains: “Science has already ridden to the rescue to a point. We already have some pretty good first generation vaccines. We’ll get more and that will

spread our levels of protection. We’ve already got some drugs for treatment that are better than they were. There’s no doubt mortality is lower. We will get anti-virals, the first ones are beginning to come out now and I’m sure they’ll be improved on. Looking forward five years, my expectation is we’ll have quite a wide suite of medical countermeasures. It doesn’t make the problem go away, but it does de-risk it very substantially.” All of this comes with a strong caveat that ‘there may well be variants that escape the vaccines to some degree.’ And he is clear that the forthcoming winter is going to be tough for the NHS, both in general practice and secondary care. “We’ll undoubtedly have Covid. We may have a significant surge, although it’s hard to be certain at this point, and the probability is we’ll have other respiratory viruses, such as flu and RSV in children, which we had much less of last year.” Prof Whitty is under no illusions that the pandemic and its aftermath will likely dominate his tenure as CMO in England – and society – for the foreseeable future but he’s acutely aware that Covid-19 is far from the only public health issue of concern. In July he published his annual report on health in coastal towns, areas that with exceptions have significantly worse health overall due to deprivation or high numbers of elderly citizens or both. “It’s finding the areas where health needs are greatest yet where the system isn’t fully working right and trying to work out how to improve healthcare in those areas.” It’s an area Prof Whitty sees GPs as having a ‘really important public health role’ given their place at the heart of communities, but he recognises that they need to be better supported to do this given that continues

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BIG INTERVIEW

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“I’ve done many of the things a GP would recognise as traditional general practice. I think it’s an amazing job; an extraordinary career.”

the ratio of GPs to need is not even across the country. His respect for general practice is evident and he states that in another life he may very well become a GP, but ‘there are only so many lives you can lead’. And whilst he didn’t become a general practitioner in the formal sense of going through GP training in the UK, he says he has ‘always seen [himself] as a generalist’. “I only stopped practising general medicine when I took this job. I’ve worked as a general physician throughout all my previous government jobs and when I worked in Africa or Asia, I dealt with problems that in the UK a GP would deal with, because we’re fortunate enough to have a specialist primary care system. Most countries across the world don’t. So, I’ve done many of the things a GP would recognise as traditional general practice. I think it’s an amazing job; an extraordinary career.” He describes the role of GPs and their teams throughout the pandemic as ‘magnificent’, particularly in terms of rapidly adapting to new ways of working in difficult circumstances, its role in research – for example the PRINCIPLE study involving the RCGP’s Research and Surveillance Centre – and the leadership of the vaccination programme. It is this latter achievement that Prof Whitty sees as setting the UK apart from many other countries, and an area where he thinks the UK’s global responsibility lies in terms of bringing the pandemic under control. “Just providing a vaccine isn’t enough,” he explains, “GPs will appreciate this point more than people more widely, but you also need a system to deliver it. Many lower income countries have good systems for

06 | BIG INTERVIEW

providing childhood vaccinations, but a system to deliver adult vaccines in the way GPs [here] do every year doesn’t exist in many low income countries. We have to support the delivery, not just the vaccine.” Whilst ‘extraordinarily positive’ about general practice’s response to the pandemic, he is aware of the criticism GPs and their teams continue to face from some sections of the media and patient groups around access to face to face appointments. “Consultation at a distance has been necessary and right but hasn’t worked well for everybody in terms of doctor-patient interactions. The pendulum clearly got accelerated and swung far further than it would have done without the pandemic. When it swings back, it’s not going to go all the way, but where it should settle I don’t know. My view is the right people to make that decision are GPs, listening to their patients, getting the balance right.” He sees the next big role for GPs in the pandemic response, aside from continued leadership of the vaccine programme, as prescribing anti-virals at a community level, although he is clear this is not necessarily ‘around the corner’. Prof Whitty will be addressing the RCGP Annual Primary Care Conference this month where he will be interviewed by College Chair Prof Martin Marshall. Whilst he isn’t yet clear what he will say, one message he will want to reiterate is that he thinks the work of GPs and their teams during the pandemic has been ‘quite remarkable’ and that ‘when people look back on it…that will be history’s view.’

Above: Proffessor Chris Whitty at a Downing Street press conference Credit – PA images/Alamy

Below: Prof Chris Whitty speaks to GP Frontline

COLLEGE CALLS FOR ‘RESCUE PACKAGE’ FOR GENERAL PRACTICE

he pressures on general practice were already overwhelming before the pandemic, but the last 18 months have further exacerbated the situation.

According to latest figures from NHS Digital and the Office for National Statistics, there are now approximately 2,045 patients per one Full Time Equivalent GP – an increase of nearly 10% when compared to 2015. As well as the impact on patient care, the College is concerned about the toll this is taking on GPs and practice teams on the frontline. In July, we published General Practice in crisis: An action plan for recovery, outlining the key workforce, workload and wider challenges in general practice – alongside a five-point plan of realistic solutions to halt the decline that has resulted from more than a decade of underinvestment in the family doctor service. While this was launched to coincide with the appointments of new English Health and Social Care Secretary Sajid Javid and new Chief Executive of NHS England Amanda Pritchard, the Devolved

Nations are campaigning along the same lines with their respective governments. College Chair Professor Martin Marshall said: “The problems we have identified in our action plan show that pressures in the NHS are not just confined to hospitals. General practice has been running on empty for too long and the situation can’t continue for much longer without serious consequences. “We need an expanded workforce with the appropriate support and premises if we are to improve access, reduce health inequalities, ensure patient safety, and give GPs more time to care for and build trusting relationships with their patients. “We are offering ready-made solutions to the problems that have beset general practice for more than a decade, we now need urgent action and for those solutions to be implemented. If we invest in general practice, the entire NHS reaps the benefit.” In September, Martin Marshall also took part in evidence sessions with Ministers and MPs at the Public Bill Committee for the Health and Care Bill, emphasising the pressures in general practice. This was the first of three Parliamentary Select Committees in just two weeks, where the College represented the views of GPs.

THE ACTION PLAN CALLS FOR:

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Urgent delivery of the 2019 Conservative party manifesto pledge of 6,000 more FTE GPs before 2024 More time for GPs to care for patients and reduced bureaucracy to prevent GP burnout Recruitment and integration of at least 26,000 other members of staff into the general practice workforce by 2024 Infrastructure that is fit for purpose by 2024, to allow GPs to deliver care in a safe way using reliable technology GPs to have a strong voice in integrated care systems and in designing care for the communities they serve

These are high profile and influential sessions and the College takes every opportunity to participate and make the case for general practice. The Health and Care Bill is expected to introduce legislative changes that aim to further integrate health services in England, with Clinical Commissioning Groups being formally subsumed into Integrated Care Systems (ICS). Martin Marshall made the case for a strong general practice voice in ICS – but pointed out that the legislation had come at a time of immense pressure in general practice and that most GPs weren’t aware of the proposed changes. He issued a stark warning to MPs about the impact that current pressures are having on GPs and their teams, stating that around 60% of GPs have seen their mental health deteriorate significantly in the last year. The impact of workload and workforce challenges in general practice were again reiterated in Martin's oral evidence session with the Health Select Committee on clearing the backlog caused by the pandemic. Committee Chair, Jeremy Hunt MP posed a question about face-to-face appointments with GPs and Martin explained how GPs had adapted swiftly to new ways of working so that they could continue to deliver care while many other parts of the NHS had shut down. He emphasised that workload and workforce pressures were making the job of GP increasingly ‘undoable’ and that remote care doesn’t mean less work for GPs. The RCGP was also represented by Cancer Lead Dr Richard Roope, who gave evidence, highlighting what an excellent job GPs are doing in difficult circumstances to the Committee’s inquiry into cancer services. The College will continue to engage with Ministers, parliamentarians, and policy makers to fight the corner of hardworking GPs so that they have the support to provide safe care for patients, without jeopardising their own health. Join the hundreds of members who have already helped us spread the word, by sharing our action plan for England with your MP. All you have to do is enter your post code and the rest is explained here.

POLICY FOCUS

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VACCINATING THE UK The contribution of GP teams in delivering the Covid-19 vaccination programme has been truly remarkable, with three quarters of all vaccinations delivered in primary care. Amy Boreham speaks to three GPs from around the UK...

he College has supported members by highlighting issues publicly and privately that impacted on GPs’ ability to vaccinate – including the supply chain, successfully lobbying to reduce red tape for retired GPs who wanted to return as vaccinators and raising concerns about low uptake in minority ethnic groups. The College also rapidly developed resources for its dedicated section on the COVID-19 Resource Hub and organised webinars on key topics such as managing anaphylaxis and building vaccine confidence. Amy Boreham spoke to three GPs from across the UK about their experiences of protecting their patients and communities throughout the pandemic.

In Barnet, Leora Harverd, a GP at Temple Fortune Health Centre, was in the first wave of practices to deliver the Covid vaccination programme. “We were given about 10 days’ notice to prepare. It was a huge leap of faith at the time,” Leora reflected.

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On the first day of clinic, 1,200 patients were immunised. However it soon became clear that with the added complexity of creating a Covid secure environment and social distancing, space in the practice was limited. The resolution proved to be the practice car park. The team set about moving the clinic outside, erecting three marquees which provided the required space to vaccinate patients and accommodate the 15-minute wait for patients receiving the Pfizer jab, as well as toilets and a communal area for staff. Vaccinating outside at the height of winter was testing. Leora remembered how exceptionally cold it was. “We often had to go inside to warm our hands up on the radiator,” she said. In total, over 34,000 patients passed through the improvised clinic entrance. Leora says the good uptake was probably due to the high Covid death rate in the community. “I think it really spurred people on to get a jab. There would often be a congregation of patients hoping to get an end of day spare dose.” Although vaccination rates were promising, Leora and her team put every effort into finding those in the community who were not coming forward or unable to. Saturday nights were filled with vaccinating the housebound and ensuring all key workers in the local area had the opportunity. “We wanted to make sure that all eligible patients, from all walks of life, were offered a vaccine. We took the clinic to the homeless and refugees living in temporary accommodation, as well as vaccinating key workers from local supermarkets and the police station.” Leora said vaccine supply was the biggest challenge, describing one time when no supply arrived to vaccinate the 1200 patients booked to attend a clinic the following day. “Our supplies had mistakenly arrived at a practice in East London. We drove the 20-mile round trip and ensured that the vaccine was in safe hands, temperature logging it en route.” Leora describes her role in the vaccination programme as a mixture of elation and exhaustion. “The Covid vaccination programme has been all consuming, on top of running day to day general practice, but I don't regret being involved in

the slightest. We just want to do our best for our patients,” she said. Professor Azhar Farooqi, a GP in Leicester and Chair of Leicester City CCG, was concerned about misconcep-

tions, anti-vax messages and fake news about the Covid vaccines circulating on social media. He knew it was fuelling the diminishing numbers of patients getting vaccinated, particularly patients from deprived socio-economic backgrounds and minority ethnic communities. As the city’s Covid-19 cases rocketed, it became the first area to be locked down under the Government's new tiered system. “We found the reasons for vaccine hesitancy were mostly confusion about mixing the vaccine with other medication, concerns about fertility, and younger patients with less urgency to get vaccinated”, Azhar said. The most effective strategy developed and piloted by Azhar and his team was simple – GPs having conversations with patients, advocating the benefits of getting vaccinated and addressing individual concerns. Practice teams were tasked with ringing up patients who hadn't responded to two or three invitations and offering to rearrange appointments. Any patients with lingering hesitancy and questions were booked to speak with their GP. The scheme was a huge success and had the biggest impact on increasing uptake rates, with two thirds of patients contacted getting vaccinated. "For many a

NEW COLLEGE PRESIDENT

simple reminder from our team was often enough, but also giving patients the opportunity to have a conversation with their GP really helped to instil confidence in the programme. It's a lot easier to change an individual’s perception in this way as the communications can be tailored to address personal needs and concerns" said Azhar. In total, Azhar’s practice increased vaccine uptake to 95%. The strategy was then rolled out across 50 GP practices in Leicester, combined with further work in the community to debunk false information. This included GPs appearing on community radio stations and participating in Q&A sessions about vaccine safety. Events were also arranged on social media, including webinars to break down language barriers hosted by multilingual GPs, pop-up vaccine clinics and door to door visits handing out flyers with information about the Covid vaccines.

Ursula noted the essential work of the Health Social Care Board, working with local GP leaders within the College, LMCs and GP Federations, to act as the main communication hubs during the delivery of the programme. In the early days this was vital as practices faced an unpredictable vaccine supply. "The Health Social Care Boards provided much needed answers about when we could expect vaccine deliveries. In January, for around 10–12 days, supplies dwindled and good communication during these times meant we were able to plan as best we could," she said.

“There was a real sense of enthusiasm from GPs to just get the job done, which has made it even more disheartening to read about the criticism GPs have received in the media over the last few months.” Dr Ursula Mason

Over in Northern Ireland, GPs’ involvement in the Covid vaccination programme didn’t begin until January, delivering the Oxford-AstraZeneca vaccine to patients aged 80 and over. "This was mainly because it was better logistically suited to practices, and easier to store," explained Dr Ursula Mason, a GP in Belfast. The following months consisted of GPs and Trusts using a twintrack approach to immunising the rest of the priority groups.

The strong communication and trusting relationships that GPs have with their patients has proved invaluable to good uptake rates. Initially, there was a drop in the number of clinically extremely vulnerable patients taking up the vaccine at Trust sites. "It wasn't until GPs started to offer the vaccine to these patients that we saw an increase in the numbers of patients in this cohort. For many, we've been treating and supporting them for years. We've built up a strong level of trust, and patients feel comfortable to discuss any reluctance or concerns they might have had." Reflecting on the programme Ursula said; “Overall I felt there was a real sense of enthusiasm from GPs to just get the job done, which has made it even more disheartening to read about the criticism GPs have received in the media over the last few months. It has been challenging to roll out the programme in such a short space of time and continue to deliver care to patients too.” 

NEWS

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Professor Dame Clare Gerada will be the next President of the Royal College of General Practitioners from 20 November. She will take over the post from Professor Amanda Howe, whose two-year term will come to an end. Professor Gerada ran unopposed, with 84% of voters agreeing to her appointment. The RCGP President is the constitutional head of the College. Unlike the other Medical Royal Colleges, it is the Chair who sets the strategic direction and policy. The current RCGP Chair of Council is Professor Martin Marshall. Professor Gerada was College Chair between 2010–2013 and has remained on College Council as a nationally elected member since. She is currently the longest serving Council member, having been continuously on RCGP Council since 1998. Dame Clare will be the first woman for nearly 70 years and the second in the College's history to hold the position of both Chair and President. She is a member of the BMA's Council, co-Chair of the NHS Assembly and is founder and Medical Director of Practitioner Health, which provides mental health support to GPs. She is a partner in the Hurley Group and a practising GP in South London. Dame Clare is also Chair of the charity Doctors in Distress and has recently written a book, Beneath the White Coat, Doctors, their Minds and Mental Illness, with all proceeds going to the charity. Her term in office will run from November 2021 until November 2023. 

SPEAKING UP IN GENERAL PRACTICE

r Henrietta Hughes talks about her work as former National Guardian for the NHS in England

“The role of a Freedom to Speak Up Guardian is proactive, identifying hot spots in culture and breaking down barriers that prevent people from speaking out; it’s also reactive, impartially listening to those that approach us with problems and supporting them to achieve their desired outcome,” says Dr Henrietta Hughes, a practising GP in East London and, until recently, the National Guardian for the NHS in England. The 2016 Francis Report identified that a growing number of healthcare workers did not feel listened to when raising concerns in the workplace, and those that did often felt victimised. As a result, it was recommended that a network of Freedom to Speak Up Guardians be established initially in NHS Trusts and now across the health sector in England, to create a better way for people to feel safe to speak up. One of the most common barriers to deter people from speaking up is futility. “People often think that no resolution or improvements will come from speaking up,” said Henrietta. “Other reasons include conflicts of interest, or if a staff member is working in temporary employment – but when people are able to speak up, important issues can be addressed such as patient safety or bullying and harassment.” In Henrietta’s previous role as a Medical Director at NHS England, she received calls directly from GPs and doctors in training – raising concerns about

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patient safety and probity issues. Listening to these concerns, preserving confidentiality and acting to put things right were all experiences which stood her in good stead to be the National Guardian for the NHS. Five years later, Freedom to Speak Up has grown as a social movement, from 90 Freedom to Speak Up Guardians to more than 700, dealing in total with more than 50,000 cases. The mission is to embed speaking up as the ‘golden thread’ that runs through the NHS by creating awareness with an annual Speak Up Month campaign. Henrietta has also successfully lobbied for questions evaluating speaking up services to be included in the annual NHS staff survey.

"When people are able to speak up, important issues can be addressed" As a GP herself, Henrietta believes that general practice has the greatest overview of the NHS, seeing the transition between primary and secondary care services – and that ‘fostering a good freedom to speak up culture in general practice is especially important’. The work of the National Guardian’s Office is extending across general practice in England. Leeds GP Confederation became the hub of the Speaking Up programme for Leeds Community Trust, the winners of the HSJ’s Freedom to Speak Up Organisation of the Year Award 2020.

The Trust created a base of 15 Freedom to Speak Up Guardians, as well as appointing specialist Speaking Up Champions for minority ethnic groups and Freedom to Speak Up Guardians for colleagues facing issues of domestic violence and abuse. Guardians were also set up in the practice to help support vulnerable colleagues who have been shielding during the pandemic. After the Black Lives Matter movement, Liverpool Primary Care Network pledged a clear anti-racism commitment and began to look for ways to tackle racial inequality in the workplace. After discussions with the National Guardian’s Office on how best to implement ways to address race inequalities and inclusion, Liverpool Primary Care Network became the first in England to appoint a Freedom to Speak Up Guardian in addition to nine Freedom to Speak Up Champions across the network’s practices. Dr Laura Power was the first GP to become a Freedom to Speak Up Guardian and is keen to make a real difference to her colleagues and other GP practices across the community by bringing her passion for inclusion and equality to help colleagues grow more confident about sharing their concerns. Statistics currently suggest that only two thirds of NHS staff feel safe to speak up, ‘so there is still significant work to do,” says Henrietta. “The mission continues to be to foster a culture throughout the healthcare service that makes it easy to speak up, and that the appropriate feedback and action is taken to resolve problems in a timely way. The National Guardian’s Office wants speaking up not just to be embedded into the workplace, but into our day to day lives too.” Henrietta has now taken up a new role as Chair of the Institute of Integrated Systemic Therapy – a charity that cares for children and young people who are psychologically and emotionally disturbed, and continues to place speaking up, listening up and following up at the centre of her clinical practice. 

NEW FACES IN SCOTLAND AND WALES Meet the new guard at RCGP Scotland and the coming Chair at RCGP Wales

r Rowena Christmas will become Chair of RCGP Cymru Wales at the AGM in November, taking over from Joint-Chairs Dr Mair Hopkin and Professor Peter Saul. Rowena's ascent to the role follows 22 years in general practice in Trellech, Monmouthshire. She explained how the experience of rural general practice has rooted the approach she will take to her new position: “It really is at the heart of the village practice. There is an energy from everyone in our small team helping patients who are our neighbours and friends. I want to lead the College in Wales in the way I see the practice working, without ego or hubris but with authenticity, courage and as part of a determined team.” Away from the surgery, Rowena lives in a smallholding with her husband, Gavin, two teenage boys, Will and Archie, three dogs, a horse and, what she describes as, “some ancient sheep”. In her spare time she enjoys running, cycling and supporting her sons as they compete in canoe slalom events. “There is a power in being connected to nature,” she says.

"Often, when someone looks at their predecessor, they think there are big shoes to fill. In my case, there are two pairs of big shoes to fill". Rowena has had significant involvement with the College and brought a paper to RCGP Council advocating a position supporting legislation to end physical punishment of children. She also represented the College during Senedd Committee hearings on the subject. She says: “Safeguarding is going to be my priority as Chair. It cuts across such a wide range of interest areas for GPs.

n January the College introduced RCGP Scotland's Joint Chairs, Dr David Shackles and Dr Chris Williams. Together they are leading the work of the College in Scotland over their three-year term. Dr David Shackles has been RCGP Scotland’s Executive Officer for Interface and Out of Hours for the past two years. He is a practising GP partner in Perth, where he has worked for 26 years. David has been involved in GP training since 1996 and still enjoys his role as a trainer. Dr Chris Williams has been RCGP Scotland’s Clinical Lead for IT since 2018. He has been a GP for the past nine years and is currently working as a salaried GP in Grantown-on-Spey. He has also worked across Highland as a sessional GP including out of hours roles

I saw how Mair and Peter adapted quickly to guide the College through COVID-19 times and it is a reminder that none of us know what will emerge. I'm looking forward to the challenge and will be keen to work with others so that we can take the next steps for the College in Wales.” A member of the RCGP Ethics Committee, Rowena highlights her participation on the RCGP Cymru Wales "Leaders for the Future" course as influential in encouraging her involvement with the College. “It was an opportunity for me to appreciate how my experience could help colleagues. Since the course I've volunteered more and represented RCGP in the media. I'm hoping we can encourage more people to get involved in the life of the College over the next three years.” 

after completing a remote and rural GP scheme. Since coming into post David and Chris have been relentless advocates for the profession; making the case that general practice remains open and seeing patients and demonstrating the work that the profession has been undertaking during the pandemic. Alongside continuing to prioritise improving general practice workload and boosting the GP workforce, the Joint Chairs have selected climate and sustainability as their policy and campaigns priority for their term of office. The selection of this priority comes ahead of Glasgow playing host to the COP-26 Summit in November. 

NEWS

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Essential CPD High quality content Peer reviewed posters Socialise and network with peers

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ON TARGET FOR ANTIBIOTIC PRESCRIBING

he TARGET Antibiotics toolkit (the acronym stands for Treat Antibiotics Responsibly, Guidance, Education, Tools), developed with the UK Health Security Agency, brings together a huge range of resources for primary care teams. Professor Cliodna McNulty, former head of the Primary Care Unit at Public Health England and RCGP programme lead for TARGET Antibiotics, oversaw the launch of the first toolkit in 2012. “We’ve gone onwards and upwards since then,” says Professor McNulty. “Public Health England continues to support the TARGET project, and each year we improve the toolkit.” The TARGET toolkit includes a series of training resources such as clinical scenario slides, webinars, eLearning modules, pod-

COLLEGE LAUNCHES NEW MENTORING PLATFORM The new RCGP Mentoring platform has been running since Spring 2021. It's a peer-led development tool designed to support members’ career growth and progress by matching GP mentors with mentees based on similar attributes, mutual interests, skills, expertise, and locality. Resources on the platform include; bi-annual learning events, and monthly information digests. Mentees are benefiting from one-to-one support and productive discussions about career successes and challenges, advice on how to develop strengths and overcome weaknesses at work, and guidance on opportunities for professional development and advancement. One mentee using the platform is Dr Oluwatoyin Oyelakin-Elusode, a newly qualified GP, practising in the West Midlands, and part of the South East Thames Faculty, said:

casts and quizzes, covering UTIs, respiratory tract infections and other conditions for which antibiotic prescribing is often considered. Diagnostic flowcharts and patient-facing leaflets, including pictorial materials, can later be used to assist in consultations where communication may be challenging. “Practices can also take a deep dive into individuals’ prescribing behaviour – which isn’t shown in practice-level data – using the audit tools,” she explains. All materials are underpinned by behavioural theory and developed using a GP– and patient-centred approach. A randomised controlled trial showed a 4% decrease in overall prescribing in areas where the TARGET toolkit was implemented.

“For me, the mentoring scheme was my leverage to get my passion back. The fatigue of training and juggling family responsibilities, and the increasing demand on GPs with overstretched resource had subtly eroded my passion for general practice. I enjoy medicine, but realised I needed someone to help me see how I could carve a career in the overwhelming circumstances of current general practice. Luckily, my GP mentor is also a trained coach and licensed in lifestyle medicine. The mutual respect, understanding and structure to the meetings is great. Using the smart goal approach, I discussed my strengths and areas of weakness and how to optimise and overcome these. Simply having someone validating your experience and steering you forward with your strengths in mind is invaluable. I highly recommend the RCGP mentoring scheme to everyone. There's a plethora of mentors with varied experiences to glean from. I get the feeling I'll become a mentor too – out of sheer gratitude.” Mentors have also been able to develop skills in personal leadership and coaching styles and expand their professional networks.

“We find that GPs prescribe for up to three reasons,” says Professor McNulty. “Patients perceive that antibiotics make a difference to the length of their illness; GPs want to prevent complications, particularly sepsis; and there is a high level of patient demand. “The toolkit highlights the minimal difference that antibiotics make to the length of an illness. Resources also describe the complication rate, to reassure GPs that it’s very low. They support GPs with safety netting, as it’s important to reduce sepsis, and also with encouraging patient selfcare and prevention of future illnesses sign off," she said.  Access the toolkit here

GP mentee

GPs are leading the way in the effort to tackle growing global antimicrobial resistance with prescriptions for antibiotics falling by 13% in general practice between 2012–2016 – and the College is supporting them in this vital work.

“I have found the Mentoring platform easy to use, and very helpful,” said mentor Amanda Robinson. “I found my mentee interesting and they just needed me to be supportive and to encourage them to persevere with the plan they had already set out. Thank you to the RCGP for the usefulness of this platform. It provides an easy way for me to be supportive even though I have now retired.” More information about how to register as an RCGP mentor or mentee is available here.

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Dr Toni Hazell

he College’s Online Learning Environment currently has over 140,000 registered users, with access to its suite of more than 100 eLearning modules, and the full range of Essential Knowledge Updates (EKU) resources. During the COVID-19 pandemic, the eLearning team was busier than ever. New guidance came thick and fast and was rapidly converted into short, easy to digest modules with the busy GP in mind. At one point, the ‘top tips’ document was being updated daily after the government briefing and occasionally, twice in a single day as things moved quickly. The COVID-19 Resource Hub has now been accessed more than one million times and is regularly updated to keep up with changing topics, such as vaccinations and post-COVID syndrome. Dr Toni Hazell is one of the College’s two eLearning development Fellows. It is their role to review eLearning modules once an initial draft has been written by the author – usually a GP with an interest in a topic. “I review the module and oversee two rounds of peer review, where it is seen by a panel including at least one GP and a specialist in the area.” “Modules use the most up-to-date information at the time, and we review them every three years as standard, but also on an ad-hoc basis to account for new guidance or research.”

The EKU part of the programme is funded in-house with updates based on new and practice-changing information from a diverse range of references and guidelines of direct relevance to busy GPs. Each one includes the latest clinical topics, with the September 2021 edition covering chronic pain, atrial fibrillation, otitis externa and thyroid problems. “It’s literally anything that could be clinically relevant to general practice,” explains Dr Thomas Round, Clinical Lead for EKU. The core modules, published three times a year, are supplemented with Challenges (EKCs), podcasts, screencasts, and twice-monthly ‘Hot Topics’ highlighting the most clinically relevant and practicechanging papers. “We try to take the information overload away from GPs,” says Thomas. EKU presentations are also available for download and local adaptation including for RCGP Faculty workshops, within individual practices, or in study groups. Some of the eLearning resources rely on external funding from sponsors who want to raise awareness of a certain topic, but Toni is clear that the RCGP holds complete editorial control. “It isn’t an issue. Sponsors have the same aim as we do – to educate GPs – and they respect the fact that as GPs, we know what is important and practical in primary care. It’s very rare not to reach an agreement as we are all professionals with the interests of GPs in mind. My overriding interest is in making sure a course is relevant for primary care, where we start from the point of a symptom, rather than a diagnosis, so our perspective can be different from that of secondary care,” explains Toni, a GP in Tottenham. GPs can use eLearning in their appraisal. Currently there is no need to record CPD in the appraisal portfolio, but this may change from April 2022. Toni’s advice is to ‘record the actual amount of time that you have taken to do a module and implement any change, even if this is more than the suggested CPD credits for the module.’

Dr Thomas Round

Making learning e-asy

For Thomas, who practises in East London and is an academic GP at King’s College London, it was a summary of the NICE two-week wait referral guidelines that has been an interesting topic he’s worked on. “It was one of the most complicated, extensive NICE guidelines ever produced, and we really had to think about how to summarise that.” Toni says she finds rare disease modules ‘particularly fascinating’ but that they hold the risk of her ‘suspecting every patient I see of having something that in reality I will only see once in my career!’ Both Thomas and Toni agree that the biggest challenge of the job is cutting through a ‘conflicting evidence base or disagreement between subject experts’. But Toni says that ‘these situations are rare and can generally be resolved’. Both also agree that eLearning can be highly convenient: “You can do eLearning on your mobile on the train or in your pyjamas after the kids are in bed, if you want to. Our ‘Five Minutes to Change Your Practice’ modules and podcasts are specifically designed with the busy GP in mind,” says Toni. Thomas says, “It doesn’t replace face to face learning, but complements it. We have bite-sized learning with a menu of options and topics for people to try to suit their learning needs.” 

NEWS

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CLIMATE CONFERENCE: GOOD COP OR BAD COP What will our lives be like in 2050? What we know for sure is that our world and how we can live and thrive will be changed. Our future depends on the actions we take this decade; on the choices that we make now. The choice of actions is between trying to continue business as usual or starting and completing a great transformation in how we all live and work.

or 12 days in November, Glasgow hosts COP26, the twenty-sixth session of the Conference of the Parties to the UN Framework Convention on Climate Change. Will it be a good COP or a bad COP? A good COP will build on the Paris Climate Agreement made at COP21 in 2015. All nations committed to combat climate change and adapt to its adverse effects. There are already big gaps between what was agreed, what has been achieved and what needs to be done. In 2021, a good outcome will be commitment to a path that leads to a 50% reduction of carbon emissions by 2030 and to net-zero carbon emissions by 2050. This is our best chance to protect the world from the more severe effects of climate change. The goal is to limit global warming to well below 2°C, preferably to 1.5°C, compared to pre-industrial levels. Achieving this goal will not stop climate change. We have already reached 1.2°C warming and even if we stop emitting all greenhouse gases today, some warming will continue. Climate change is happening now and will get worse in our lifetimes. Ninety percent of the world’s population will face one or more of the main threats that include flooding, heat stress, water stress, wildfires, hurricanes and sea level rise. These modern plagues may have other consequences including mass migrations from the worst affected areas. In the UK we may avoid the worst of these climate changes, but we will have more frequent and worse flooding events. The best result at COP26 will be that we all work towards the 1.5°C goal and embrace the many deep and rapid changes needed across most of human activity.

General Practitioners should choose the ‘good cop’ role and work towards the 1.5°C goal. The public will look to the those whom they trust to lead the way with evidence and action. Many of the changes will improve our health through better diets, increased active travel, cleaner air and more access to nature. Politicians need doctors to highlight the compelling health reasons for climate action, and boost public consent for change. Practices should be planning how to manage this challenging future of new threats and great changes and be influential role models for change in our communities.

"There is evidence and guidance available on what we can do in our practices for a sustainable future" There is evidence and guidance available on what we can do in our practices for a sustainable future. The first step is to check the advice on the RCGP website’s sustainability page. The next step is to join Greener Practice the national hub for the local support networks that will help general practices in the transition to environmentally sustainable healthcare.

To be able to look forward to a safe and secure future we must act now. A bad cop role will be to ignore the threats and remain unprepared for the challenges of the climate crisis and leave us living unhealthy lives on an unhealthy planet. The ‘good cop’ is the right role for general practice. 

Terry Kemple, RCGP UK representative for Sustainability, Climate Change and Green issues Dr Aarti Bansal, England Dr Munro Stewart, Scotland Dr Sarah Williams, Wales Dr Bláthnaid Carlin, Northern Ireland.

OPINION

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Midland Faculty held meet and greet events to engage with trainees, and special sessions to support them with exams; while the Welsh faculties put on mindfulness and meditation sessions and held an online event to help members manage anxiety and depression. Recognising the profound emotional and physical fatigue care providers have been working under since the onset of the pandemic, the North East London Faculty, working with local NHS partners, held the 'Health Equity Restoring Hope Festival & Celebration' in February to ‘lift the spirits’ of the local community. With GPs registering in their hundreds, there was clearly an appetite for hope. Dr Liliana Risi, NEL Faculty Provost, said “We work closely with our NHS Partners to co-fund all of our events so that they can be open access. These relationships are key to our success in our Faculty.” The virtual event was held over three evenings, and tribute was paid to London residents and health and care workers who had died since the onset of the pandemic, many of whom came from ethnic minority communities. Joint Honorary Secretaries of the Faculty Dr Shani Bhaskaran and Dr Sally Smith hosted and led the event, which included patients, GPs, public health colleagues, medical students and community organisers sharing positive stories from throughout the pandemic, intermixed with presentations of music, poetry and art from Queen Mary University London (QMUL). Sector leaders were invited to give 'elevator pitches' on fairer environments, resilient systems, strong communities and resourceful people. Dr Risi said, “Whether it was the story of enhanced partnership working with the voluntary community sector in Newham, a trauma-informed approach to care in Hackney, or QMUL's vision for how communities can shape the medical curriculum for a socially accountable medical school, there was no shortage of inspiring local work to share. It was clear that the pandemic has not stifled innovative efforts to improve patient care and build healthier and more resilient communities.” Islington GPs shared how they worked with SHINE London, a fuel poverty referral network offering free energy advice, to identify patients who were struggling to heat their homes during the pandemic. This ensured they were able to stay warm through the winter, as well as removing the significant stress this was causing the patients. Elsewhere, in Tower Hamlets, Communities Driving Change (CDC) worked in some of London's most deprived neighbourhoods to identify issues impacting health and wellbeing, and promote social prescribing initiatives to address them. Dr Risi added:“This was an event to restore hope at the most difficult of times. At the beginning of the pandemic in particular, services upon which patients depended faced massive uncertainty, and the risk of worsening health inequalities loomed large. “Delegates left with a story of systems coming together, from health and local government as well as the voluntary, community and faith sectors, to identify health challenges that need to be addressed and deliver real results for patients against all odds.” Another Restoring Hope Festival & Celebration is planned for the 22–24 February 2022. 

10 M N. I

hroughout the pandemic, RCGP Faculties across the UK have continued to put on virtual events to support members. Cian Daly reports...

T LTA IO

NET-WORKING

DR CARTER SINGH MBE GP in Nottinghamshire, Faculty Representative on Council and Vice-Chair on the Nottinghamshire LMC.

WHY DID YOU CHOOSE TO BE A GP?

I wanted to be an expert generalist, rather than becoming overly focussed on one field of medicine. I wanted to develop long term doctor-patient relationships, because I think continuity of care is therapeutic in medicine.

WHAT’S THE BEST THING ABOUT BEING A GP?

Variety. Not only the case-mix of patients, but the flexibility and the myriad career options GPs can pursue.

WHAT’S THE MOST FRUSTRATING THING ABOUT BEING A GP?

I love the job, but it comes with constraints – system, regulatory, financial, workforce and so on – which take a toll on our autonomy, our wellbeing and our work-life balance. As a result, GPs can end up suffering from burnout.

WHAT ARE YOU MOST PROUD ABOUT IN YOUR CAREER?

Being awarded an MBE for the work I’ve done, with ethnic minority communities and learning disability patients to help reduce the health and social inequalities they face.

HOW CHALLENGING HAS THE PANDEMIC BEEN?

It’s been challenging. It’s thrown up VUCA: volatility, uncertainty, confusion, and ambiguity. We’ve had to deal with the loss of our friends and family, and the mental health and social challenges of lockdown and self-isolation. But we’ve learnt lessons – for example about working differently and at pace, and retaining resilience – and I look forward to putting them into practice moving forward.

WHAT HAS BEEN THE MOST IMPORTANT LESSON YOU’VE LEARNT DURING YOUR CAREER?

If you choose the easy short-term path, your life will be hard in the long-term. And if you choose the difficult thing to do at the time, your life will be easier in the long-term. It’s a career lesson and a life lesson.

WHY DO YOU THINK IT’S IMPORTANT TO BE A COLLEGE MEMBER?

It’s a fantastic way to network and build strong professional relationships. I think like most things in life, you get out what you put in. Your contribution can make real change, and the College is ultimately there to improve patient care, which is what we’re all in it for.

WHAT WOULD YOU BE IF YOU WEREN’T A GP? Unfulfilled!

GP LIVES 21

23 20 | GP LIVES

GERDA POHL

VICTORIA HOLT

MIKE VARSHAVSKI

MEDICINE IN NEPAL Dr Gerda Pohl discusses two decade improving medical care in remote communities

hen the Nepal earthquake hit in 2015, Dr Gerda Pohl had spent many years travelling to and working in the country. At the time, she was supporting the work of PHASE Worldwide in Nepal – a charity she had co-founded in 2005. She is almost lost for words when describing the devastation which killed 9,000 and injured 22,000. “The earthquake was a major disaster, hard to imagine. I was visiting a project in a village at the time and every single house was reduced to rubble and everyone who was inside a house was either injured or dead. She adds: “We spent time doing first aid but we were completely cut off. The following day a small team of us walked for half a day along the road that had been blocked and all we came across were people burying their relatives and people being brought out of the rubble. It was apocalyptic.” One striking aspect that sticks in Dr Pohl’s mind is how everyone stepped up to help each other out. “Every single health professional just turned up at work, the local army did all the digging and in the remote communities they just helped each other, it was really impressive.” Overnight, her voluntary work with PHASE Worldwide changed from health systems development work to managing a relief project. “It wasn’t so much medical skills that were needed at that time. What they needed was food and shelter – the basics. “Most of the PHASE projects in the far west of Nepal didn’t get affected by the earthquake which also meant we could provide some relief staff for a few weeks in the districts badly affected. Even now not everyone is fully recovered. You don’t really get back to completely normal within a few years.”

While still a trustee of PHASE Worldwide, the 52-year old who grew up in Austria and Germany as well as spending time in Africa, is currently working as medical director for the Gurkha Welfare Trust (GWT). It is a role that brings together the skills she learnt as an NHS GP working in South Yorkshire and her work in Nepal over the past two decades. Her previous work in Nepal had included setting up antenatal care and finding ways to tackle child malnutrition. Now working with Gurkha veterans through the 21 clinics and 160 medical staff the charity has throughout Nepal, the focus is on diseases of ageing. “It seemed like this job was designed for me because it brings together all the things from my NHS role and charity role. We aim to deliver healthcare comparable to that in the NHS but providing that level of care is not so easy because of the context.” What it means for her medical staff is up to date knowledge of chronic disease management. “Almost everyone has hypertension or COPD or diabetes. It’s interesting to develop skills like setting targets, lifestyle education, shared decision making, keeping up to date and so on and that’s where friends and colleagues from the UK can be really helpful.” The remote nature of some communities in Nepal brings specific challenges says Dr Pohl. The GWT has seven big clinics in urban centres with doctors providing family care and 14 smaller centres with advanced nurse practitioners in constant phone contact with the doctors and prescribing all done remotely. The Covid-19 pandemic seriously impacted the GWT, given the demographic of the patients it helps. In response, it switched to remote consulting where possible and steppedup home visits to reduce the need for elderly patients to visit the centre. It also ‘sealed off’ the Trust’s two residential homes, with staff living on site

to maintain infection control; however, despite their best efforts, two of their 38 residents sadly died. Now that all staff and residents have been fully vaccinated, the staff are commuting again; but lack of vaccines across Nepal, including second doses for vulnerable people, remains a key concern. “I’ve been involved in Nepal for coming up to 20 years and there have been huge changes in many areas. When I first started there were a lot of young children who didn’t go to school and that has been almost eliminated now. Rates of maternal care and maternal and child death have really improved. A lot of villages had no access and now have a road. And the government has invested a lot in building skills,” she says. Her aim is now to do more work on developing services to meet the needs of a group of patients who are getting older and frailer. “When they have a fall or illness, they may need round-theclock medical or nursing care for a while; we run two nursing homes and we have developed some space for rehabilitation for short-term care.” She adds: “We are also trying to develop palliative care services – that is one of our biggest projects for the next year.” 

GP LIVES

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Grainge photography

SHAKING UP THE SYSTEM Dr Victoria Holt, the East London GP who has worked cooperatively for patient care.

r Victoria Holt describes herself as a City and Hackney GP through and through. It is where she did her GP training after winning one of four places for which there were 80 applicants. And it is where she took up her first job in 1989 as a GP in the Hoxton Health Collective, pioneering a completely different model of general practice. Initially based in a two-bedroom council flat, the East London practice was, at the time, doing something very different. But much of what set them apart then is now a routine part of general practice, she muses. “Lots of things we did were very much ahead of their time. Patients got to hold their medical records while sat in the waiting room, for example. There was much more of an extended role given to nurses. We had a counsellor in-house as an integral part of the practice team.” The financial and management model was based on everyone in the team receiving the same hourly rate of pay and shared decision making on everything from how the appointment system ran to what clinics the team would offer. “As a socialist and feminist, the conventional general practice partnership model did not appeal, and I liked the idea of a collective. We had this vision that lots of practices would start doing it; there was a feeling we were at the beginning of something.” The move to the new premises in the early 1990s may have altered the surroundings for the collective, who were now housed with other practices in a large medical centre, but it did not change their approach for patients, she stresses. “All of a sudden we had oceans of space it was totally luxurious, each having our own consulting room, but it didn’t change what we were doing with patients.”

“Lots of things we did were very much ahead of their time” Yet by the early 2000s it became clear that the practice was no longer sustainable, with staffing a major problem. “No doctors wanted to work there and we were limping along with locums and we realised it wasn’t a sustainable model. After the decision was made to fold, it was a real mixture of sadness but also relief because it had become so incredibly difficult. But it was an amazing bunch of people and we’re still friends now.” At 58, Dr Holt’s main focus since then has been on out of hours and urgent care services. At the Hackney Health Collective, they had initially shared out of hours with another local collective GP practice and the whole team took a share of fielding calls before passing them to a doctor if necessary for more advice or a visit. The increasing burden on out of hours for GPs in Hackney later led her to start a GP co-operative where doctors worked on a pro-rata share. After the new GP contract came in in 2004, Dr Holt became education lead for Camidoc who were providing out of hours services across City and Hackney and three other boroughs. “My career seems to have been jumping from sinking financial ship to sinking financial ship,” she says jokingly, explaining that in 2011 Camidoc was also forced to close – something which actually hit her harder than the end of the Hoxton Health Collective. “In a funny way I was more upset about that one as it was a total shock and I wasn’t feeling burdened with its

responsibility, but I was furious and devastated.” Her next role was as clinical lead for CHUHSE – a social enterprise which provided out of hours care in the borough until 2019 when NHS111 was mandated as the call handling and advice service nationwide. It had become increasingly difficult to staff the shifts at the end, she said, and it meant she was filling far too many of them herself. “That was punishing. There were a few years where it was hard to plan my life and that was really difficult for my family.” Now she is part-time clinical lead for the urgent care centre in the A&E department of the Homerton Hospital and sharing the leadership of the Homerton GP OOH face to face service, as well as doing some appraisals. “I never had a plan for my career and some of this has evolved though chance conversations,” she says. “The thread through it all is about me being a City and Hackney GP, and providing round the clock care for patients has been at the forefront of what I have prioritised.” 

RCGP archive image from Hoxton Health Collective

22 | GP LIVES

SOCIAL MEDIA MEDICINE Dr Mikhail Varshavski, better known as Doctor Mike to his millions of followers, is using social media to cut through fake news e was born in Saransk in the Soviet Union, before moving to New York, aged five, with his family. He knew he wanted to be a family physician – the equivalent of a GP in the US – following in the footsteps of his father, who was a physician in Russia, and retrained in America from scratch in his 40s. “I was nine or 10 when I got to witness what it takes to become a doctor: how special it is being a family medicine physician…the relationship my father developed with his patients, the blessings he got when he helped a patient through a hard time, I fell in love with the field, especially when you couple that with my natural curiosity for science and the human body.” Mike lives in New York City with his two dogs, Roxy, his family husky and Bear, a 150-pound Newfoundland, and practises over the river in New Jersey. He’s also an award-winning social media superstar with 7.6m followers on YouTube and 4m on Instagram, as well as a presence on TikTok, Twitter, Facebook and regular TV appearances. He’s also given a TEDx talk that has been streamed more than 2.6m times. Splitting his time about 50/50 between social media medical work and practising medicine, Mike says: “In family medicine you need to be a very powerful communicator and influencer. It isn’t a term you hear often when we’re talking about medicine – it’s often looked down upon, people assume you’re trying to sell snake oil. Doctors can be good influencers, as long as social media is used for the right reasons.” His social media channels contain videos that aim to both educate and entertain, ‘delivering accurate information, and challenging misinformation,

in a way that’s easy to understand, and that’s fun sometimes.’ Mike’s foray into social media started during his medical training, where he documented his day to day life as a medical student on Instagram. “I wanted to get the message out that you could be a physician and still have a good time. There was a myth that you had to give up your life, which is partially true but not 100% accurate,” he says. “I built up a small following, and just after my first year of residency I experienced this viral moment. Buzzfeed, Cosmopolitan, other major magazine outlets wrote a story about me, but it was nothing to do with medical stuff.” “I suddenly had a lot of invitations to do national media. Every time I did a programme, the conversation would be ‘are you single or are you dating?’ and I really wanted to move the conversation on to things I was actually passionate about – preventative health, myths in medicine, not just my dating life.” Whilst Mike says there are times when he finds this embarrassing, he also says he’s ‘embracing it’. “It’s the ‘scandal’ that makes the media interested in me, but I can use it to get into some meaningful content…the advantage is millions of people are watching and getting quality [medical] information when they think they’re getting fun and silly things to look at.” Mike sees social media as a way of connecting with a large number of people and increasing health literacy – something that has been particularly important during the Covid-19 pandemic. But he’s aware of its downsides. “I get trolls and people being very angry with me when I put out medical information that contradicts their beliefs. There was a popular conspiracy theory

documentary called The Plandemic. It was full of misinformation and I did a 38-minute video debunking it point by point. I got a lot of hate for that. It’s part of the job. But it’s not just trolls, it can be well-intentioned people putting out inaccurate information. “There’s a dark side, but villainising it isn’t a solution, [social media] isn’t going anywhere and as GPs we have to go where our patients are – their eyes right now are on televisions and social media, so if we’re not there, the absence of quality evidence-based physicians is going to be filled with nonsense. “I’m not talking about making people scientific experts…but basic knowledge will go a really long way to changing the world from a healthcare perspective,” he says. He also acknowledges his responsibility as both a physician and an influencer, particularly when it comes to sponsorship: “You need to have a very strong moral compass. Every time a sponsor comes to my channel, I consider it thoroughly in my mind – is it ethically and medically responsible? I’m not a typical influencer, there’s medical information there and I have the trust of my patients. Integrity is vital.” 

GP LIVES

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Pioneers of general practice

The College’s online exhibition Women at the heart of general practice celebrates the achievements of some of the women who helped make general practice what it is today. Philip Milnes-Smith reports... Several generations of women GPs had practised before the College was founded – most of whose stories are not in the College archives. One was Octavia Wilberforce (1888– 1963), great-granddaughter of the abolitionist. In 1913, when, very much against the wishes of her family, she was looking to enrol at the London School of Medicine for Women, it was suggested to her that medically qualified British women generally ‘did not have private practices’. The first women practising in Harley Street (like Mary Scharlieb, 1845–1930) usually had portfolio careers. The 1911 England census includes seven women identifying as General Medical Practitioners who had qualified between 1891 and 1910. Agatha Porter (1852–1934) who had already been listed as a GP in the 1901 census, was in Notting Hill. Nena Beatrice Levers (c.1883–1957) was an Assistant in Willesden. Margaret Sophia Sharp (1871–1963) was in Bradford. Margaret Scott-Dickson (c.1880–1952) who subsequently practised in Dundee,

was in Redditch. Ada Jackson (1869–1956) was in Hull. Martha Beatrice Webb (1863– 1951) was in Edgbaston, and Rhoda May Murdoch (1886–1972), who subsequently practised in Preston, was in Rotherhithe. When Octavia (pictured above, far right) set herself up in general practice in Brighton in 1923, she was taking a gamble. She purchased premises with loans from friends and set up her brass plate rather than taking on an existing list, noting that ‘it’s not generally considered wise to buy a man’s practice’. She supplemented her income at first with hospital work, which also led indirectly to introductions to new patients (‘the mistresses of the maids I helped in Outpatients’). She earned a respectable £308 in her first year. Octavia was typical of most of these medical women from the point of view that she never married, although Grace Harwood Stewart (1872–1957) continued her career after marrying a Cheltenham builder. He described her as Doctor of Medicine, rather than a GP, in the 1911 census, but altered the windows in the

front room of their new home to let more daylight into her surgery. Octavia enjoyed what she termed “over forty years of close association” with the actress, writer and suffrage campaigner Elizabeth Robins, who provided moral and financial support for Octavia’s career in medicine, and whom Octavia viewed as her adopted mother. The subsequent lack of descendants to unmarried GPs like Octavia has perhaps been a factor in their pioneering contributions being overlooked. It was said that “women could do remarkably well in an ordinary family practice” since treating a mother and her children would usually lead to treating the husband and father. By the mid-1920s, Octavia was able to boast of a friend’s success, possibly Kathleen Field (1886–1970): “In three months she doubled her practice, and now has more men than women patients. The other day she received a deputation from Great Western railwaymen asking that 250 of them should be transferred to her panel.” 

COLLEGE PREPARES TO MARK 70TH ANNIVERSARY – A MESSAGE FROM THE PRESIDENT

The work we are doing on collecting stories of our experiences as GPs of the COVID era will feed into this, and we’ll give you details of how you can contribute shortly. We’ll also be hosting the World Organization of Family Doctors (WONCA) European Regional Conference alongside our RCGP conference from June 27–30th, which will give us a chance to share our history with international delegates though talks, displays, and visits to practices. We hope that College members will use their own networks to mark the occasion. Some groups have already suggested aligning their own Faculty and other planned educational events with themes that celebrate the anniversary.

We plan to have online resources that you can easily draw down for presentations or group discussions. You may want to make your own podcasts and webinars or consider other ways to celebrate general practice and the contribution the College has made. The College is its members – and we want you all to be part of our Platinum anniversary! Please contact RCGPat70@rcgp.org.uk with any ideas you would like to share. 

The RCGP celebrates its 70th anniversary in 2022 – and we want your ideas for how to mark this special time in our history. We envisage that the majority of events will run for six months between Easter 2022 and the November AGM. We plan to have an online exhibition on the history of the College, as well as running webinars and other Membership and Fellowship events.

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Professor Amanda Howe