Giving a Personal View on how we save General Practice
Thursday, 02 November 2017
Professor Ronald MacVicar, Postgraduate Dean, NHS Education for Scotland, Centre for Health Science, Inverness.
Originally from the Isle of Skye and trained at the University of Glasgow, Ronald MacVicar has been a GP in the Cairn Medical Practice in Inverness for almost 30 years, though retiring from clinical practice in summer 2015. He undertook his GP training in the West and North of Scotland as well as spells in New Zealand.
He has been heavily involved in postgraduate medical education for some time, initially as a GP trainer, then as Assistant Director of Postgraduate GP Education from 2004 and Director from 2008. In this role he has had wide-ranging responsibility for GP education in the North of Scotland as well as national responsibility for areas including; remote and rural training and education, GP Fellowships and Scholarships, and Continuing Professional Development. In the new single Scotland Deanery, as well as regional responsibilities and GP-related responsibilities, he has co-led the Quality Workstream.
Ronald is a Fellow of the Royal College of General Practitioners (RCGP), awarded in 1994 through the arduous Fellowship by Assessment route, and he led his group of practices to the RCGP’s Quality Practice Award in 1998, the first such awarded to a group of practices in the UK. In 2001/ 02 he undertook a year’s sabbatical in Southern Ontario, learning from the innovative educational approaches at McMaster University and undertaking an academic fellowship at the University of Toronto. One concrete result of this experience was importing and modifying for Scottish General Practice the Practice-based Small Group Learning (PBSGL) programme. PBSGL in Scotland is now well established and renowned with over a third of Scotland’s GPs being regularly involved in PBSGL.
His key areas of interest include professional development, quality improvement, supporting remote and rural service and education and, as a deputy editor for the journal Education for Primary Care, advancing General Practice/ Primary Care as a scholarly discipline.
Note of meeting held on 2nd November 2017.
The President, Dr Andrew Robinson introduced the evening's speaker, Professor Ronald MacVicar, Postgraduate Dean in the North of Scotland who worked in General Practice in Inverness for almost 30 years until 2015. In talking to his title of "Giving a Personal View on How We Save General Practice", Professor MacVicar serially challenged members of the audience to interact in the discussion of problems and potential solutions. He offered some illustrative figures throughout, beginning by answering his first question on whether General Practice needs saving by explaining that one third of GP training places in Scotland are currently unfilled; he added the rider that this included the 100 extra places announced by the Government in 2016 - when available places were already under-subscribed.
Proceeding to the question of whether or not we should save it, Professor MacVicar explained that many health systems in the world do not have anything that we would recognise as General Practice. He spoke about the importance of having a comprehensive primary medical care system, and referred to the work of Barbara Starfield of Johns Hopkins University in Baltimore, which had provided evidence that systems with strong primary care provide more efficient and better quality health services.
He then produced two stones which he had brought from his office in inverness. The first had been removed from the ruins of a house in Borreraig in his native Isle of Skye when an inhabited area had been cleared in the 1860s when the said community was no longer sustainable. The second was a piece of Skye marble which had been mined in the south of Skye early in the 20th Century by miners of mainly Italian and Belgian origin. The start of the Great War had led to the workforce repatriating and their work being abandoned. Both stones therefore said something about the existence and potential fragility of community and reminded us of the vital social capital that is local health care whereby loss of a General Practitioner will undoubtedly challenge the survival of small communities.
Professor MacVicar went on to say that he had, earlier in the day, addressed the annual gathering of some 100 GP trainers in Nairn; he proceeded to share some of the issues raised as currently important by the delegates including relationships between primary and secondary care, flexibility and resilience, knowing when to say 'no', meeting expectations, society's demands, 'ownership' of patients, a need to move focus in medical school from hospital to community. A show of hands among the audience in Aberdeen reaffirmed the fact that all who (had) worked in GP had spent time working in hospital, but virtually none of those who (had) worked in hospital had experience of working in General Practice.
In sharing the GP Trainers' Conference comments, Professor MacVicar observed that the issues were more often about problems than solutions and so he invited the audience to comment on any solutions. Dr Ken McHardy, retired Diabetologist, spoke of his work over two decades in Diabetes where there had been great emphasis on identifying and promoting synergistic working between primary and secondary care teams for the primary benefit of the patients, but with added advantages for the professionals. Prof George Youngson, retired paediatric Surgeon, made the point that recruitment has been difficult in a number of specialties, including surgery and medicine, suggesting that perhaps the recruitment issues were not necessarily peculiar to General Practice. Prof MacVicar agreed, adding that inadequate numbers are progressing at each stage through medical school, foundation programmes, specialty training and into senior posts; he pointed out how difficult staffing had become since major changes were made to immigration rules for postgraduate doctors around 10 years ago. Dr David Galloway, retired Clinical Pharmacologist, asked the extent to which the European Working Time Directive and its 48h weekly maximum had contributed to changing medicine from a profession to a 9 to 5 business; Prof MacVicar acknowledged this but also pointed out the difference between traditional office hours and a 48 hour week that may involve many antisocial working hours.
Dr Ron Wallace, a recently retired GP, was among the first to highlight the need to have some positive role-models in General Practice, lamenting the disappearance of the likes of Dr Finlay's Casebook with its cheesy/cheery title character. Professor MacVicar lamented the ingrained culture that makes politicians invariably equate 'Health' with 'Hospitals' and he observed that the GMC's new booklet of standards, 'Promoting Excellence' depicts the archetypal patient as someone in a hospital bed and on an iv drip! President Elect, Stephen Lynch, a City GP, stated that medics are consistently too negative about GP as a career, and that GPs must stop moaning in front of students. Fellow City GP, Dr Bill Reith, made the point that 'General Practice' and 'Primary Care' should not be used interchangeably for fear that deficiencies in training and provision of Medical Practitioners in General Practice are resolved less effectively, appropriately and expensively by substitution with non-medics. Professor MacVicar added a similar view whereby politicians discuss solving mental health service deficiencies by providing more clinical psychology input rather than recognising a need for more psychiatrists. Dr Nanette Milne, declaring her main professional identity as a medical politician, spoke of how when she had trained in the 60s, students were given the impression that General Practice was almost viewed as a 'failed' medical career with the elite posts being in hospital. She explained things were progressively improving until a hospital consultant was appointed to the post of Health Minister, setting things back again.
Referring back once more to the 100 trainers, among views expressed on how to save General Practice included the need for a well-resourced medical school, education of those advising on careers and the avoidance of expressions of negativity around General Practice to students. Professor MacVicar went on to share some of his own further thoughts and observations. Referring to a study by Dowell et al on widening access to medical school, he highlighted the findings that there is a significant correlation in Scotland between the regional and rural/urban origins of medical practitioners and where they settle down to work after training. While there is encouraging similarity between such socio-geographical proportions in the Scottish population and the students attending Scottish medical schools, there is a major problem when it is realised that native Scots comprise only about half of these students. As trained doctors tend to 'go home' we need more Scots recruited to medical school places.
On the question of choosing General Practice as a postgraduate specialty, reference was made to the paper, 'By Choice Not Chance', produced by Higher Education England which had explored how undergraduate experiences may impact. The adverse impact of negativity and discouragement from GPs was highlighted. Recommendations unsurprisingly called for positive role models, positive recruitment strategies and cessation of undermining language. Professor MacVicar challenged the view that General Practice is boring, saying more needed to be made of its variety and constant intellectual challenge. It was also pointed out that while Aberdeen was highest among Scottish medical schools with over 1 in 3 recruited into General Practice, in Edinburgh, this was under 1 in 5.
Professor Donald Pearson, retired Diabetologist, suggested that perhaps more could be made locally of the fact that Aberdeen's Medical Students have a high preponderance of specalisation in General Practice. Prof MacVicar reminded us that while the success in recruitment rate was indeed encouraging, it was well below the figure of 50% that the service needs. Dr Michael Williams, retired Diabetologist, said that he had no training in General Practice in Aberdeen in the early 1950s and asked whether all medical schools now included this. Professor MacVicar explained that all students needed to have 4 weeks of GP training in their 5 year course, while reminding us that over 90% of medical encounters occur in General Practice.
Professor Youngson told the group that a disproportionately high number attending medical school in Edinburgh had ambitions in surgery and indeed contributed a larger proportion of surgical specialists in due course. This led to the issue of how soon doctors of the future may be deciding on specialisation choices - and hence the likelihood that for careers advice to have an impact in favour of any particular specialty it may need to be starting in junior secondary school! Professor MacVicar said that while Edinburgh had a high medical academic profile, there may be an argument in favour of all of Scotland's medical schools being expected to contribute more to supporting the needs of the medical workforce. Dr Angus Thomson, retired radiologist, recalled the situation in the 1970s when he was training and a large proportion of senior doctors were raised locally; he wondered where all of the local people had gone that there were now shortages. Professor MacVicar acknowledged the reduction in influence of 'being known' in modern times when the medical workforce was also potentially more mobile, even after attaining what were once considered 'permanent' jobs. Dr Peter Duffus, retired GP, said there had been scant mention of Mental Health or General Practice when Professor Steve Heys had given an account to the Society of the local Medical School's organisation and priorities earlier in the year.
Professor MacVicar then asked the audience directly what they thought they could do to take important ideas forward when discussing medical careers and securing sufficient support for General Practice as a desirable choice of specialty. Dr Judy Farquharson, GP, gave the view that there is insufficient pride in a specialty often portrayed at medical school as dull, dry and boring adding that early GP experience for students may well be rather dull, She also suggested that students do not like dealing with uncertainty - yet, General Practice is very much a specialty concerned with dealing with uncertainty. She hoped that things had moved forward from the situation a few years back when it seemed that GPs were being regularly blamed for almost all that was wrong with medical services.
The audience were then reminded of recent work by Jen Clelland and Peter Johnston in which a discrete choice model had been used to ask, in turn, what medical students and junior postgraduate trainees most wanted; both groups gave highest priority to good working conditions. A Kings Fund study on established GP systems had highlighted the value of small group education as being at the heart of highly successful GP training in Christchurch, New Zealand. Professor MacVicar reminded us that Practice-Based Small Group Learning was a well-established system used in Scottish GP training and support. (He did not mention his own important role in promoting this model over many years.)
Dr Pierre Fouin, retired GP, then raised the matter of what he called 'the elephant in the room' by which he was referring to the development over several decades of a system whereby General Practice is now predominantly provided by part-time workers such that, in the practice where he is a patient, a complement of 1 full-time and 7 part-time GPs effectively means that the continuity that was once a major component of primary care is now virtually non-existent. He suspected that educators did not want to face up to the problems of part-time service delivery and work out the most effective ways of deploying the resources of part-time staff. Dr Harry Smith, retired GP, extended the challenge by suggesting that we have not been training a workforce that can deliver what the service needs - and that affects most specialties; it was little wonder therefore that most doctors are inclined to moan about the hopeless conditions in which they are expected to work.
Professor Youngson returned to the theme of uncertainty saying that it is intimidating, as is the notion of generalisation in view of its greater attendant uncertainty. The increasing emphasis on safety - which, he asserted, comes with specialisation - was discouraging generalisation in the senior medical workforce. In response to his suggestion that some form of partial specialisation may be the way ahead, led Professor MacVicar to remind the audience of the currently ongoing work in response to Greenaway's 'Shape of Training' report which is deliberately moving back from subspecialisation to 'general specialisation' for all postgraduate training programmes, with full subspecialisation being the ultimate destination of a relatively modest proportion of completing trainees.
Dr McHardy returning to the theme of local workforces being a favoured domain of local people lamented the difficulties in mentoring, supporting and hence attracting rising local stars to senior training that had come with the annualisation and nationalisation of recruitment into training programmes since the advent of Modernising Medical careers some 10 years ago. Professor MacVicar agreed that an appropriate balance between principles of fair and consistent national recruitment, and a need to support local services by encouraging locally-derived graduates had not been attained.
Dr Mustafa Osman, Paediatrician and Associate Postgraduate Dean, suggested that in addressing the difficulties, the profession had to focus on the things that it could potentially change and he encouraged movement away from the traditional binary distinction between primary and secondary care, highlighting the potential of synergistic working where possible. He suggested that the Medico-Chirurgical Society could perhaps help by supporting and promoting networking, linkage and collaboration. Professor MacVicar agreed that we had become too accustomed to the ways that we had always been used to.
Dr Bill Reith recalled the time in the 1960s when the response to a recruitment crisis into general Practice led to the establishment of the GP Vocational Training Scheme. At that time, some wanted a 5 year training programme but various pressures led to this being condensed into 3 years. He bemoaned the fact that more than 40 years later the GP training programme has hardly changed and despite the ever-growing complexity of all aspects of medicine, still comprises only 18 months of training based in general practice. He asked why only this specialty had to train its specialists in 18 months.
Professor MacVicar concluded by thanking the company for their enthusiastic input to the discussion and reminding us that educational differences that count in providing and sustaining quality health care can be made in postgraduate training, in medical schools, and indeed in pre-university schooling.
The President thanked Professor MacVicar for his presentation and the audience for their participation and adjourned the meeting with a reminder of the next meeting on his programme on 7th December when Miss Moira McCormick will talk on ‘Providing Physiotherapy for the Royal Ballet and the Challenges of Hypermobility’.