Dr Jo Butterworth, GP and NIHR Doctoral Research Fellow.
“How are you 300 ahead of me?!” said my colleague, arriving at her desk to start a new day’s work. “Sorry?” I said, finishing off a mouthful of breakfast bar. I already knew what she meant. We’d been ‘competing’ like this for a few days now, egging each other on to maintain our momentum and get through the work on schedule. “Titles and abstracts! You’ve screened 300 overnight!” My mind went back to yesterday evening, sitting in the kitchen watching the potato wedges turn crispy in the oven whilst I flicked through “just a few more” articles on my mobile screening app. I guess that’s the way with screening isn’t it? At the start it’s like being confronted with a gigantic raw potato but once you’ve peeled the skin, gotten rid of a few knobbly bits, you just keep chipping away…
“… if we’d had all of the ingredients to make a shepherd’s pie then we would’ve made a shepherd’s pie, so next time we’re in the kitchen we might think about peeling a few more potatoes.”
In the case of our review of interventions, the evidence was fairly small fry and study authors had chosen different outcomes resulting in a lack of data which could be combined in our analysis. We reached the nevertheless important conclusion that further research was warranted and we made suggestions as to how research teams might go about this.
I never set out to lead on a Cochrane review; my funders thought it might be more than I could chew. However, when both I and the team from Manchester applied to update an existing review, Cochrane served up a sharing platter and suggested that we start with a clean slate. Now, when you’re posing your question and designing your search strategy, you’re just at the tip of the iceberg, with little real idea about where this might lead in terms of the workload ahead. Well, I can tell you now that there is nothing bite-sized about a Cochrane review.
Serving up and submitting a Cochrane review is what I imagine being a contestant on a well-known television cooking show might be like. You know you won’t get through to the next round if it doesn’t look, smell and taste just as the judges expect. However, there is plenty of guidance available to authors to ensure that their writing is up to standard.
There is also a lot of suggested text, which must not be left out, even if it does not seem applicable. For example, you’re expected to say something like, “if we’d had all of the ingredients to make a shepherd’s pie then we would’ve made a shepherd’s pie, so next time we’re in the kitchen we might think about peeling a few more potatoes”.
Carrying out a Cochrane review is, all-in-all, a highly valuable learning experience and it is the gold standard approach to a systematic review. I am grateful that I have been through the process and for the more sophisticated research palate that I have undoubtedly acquired along the way.
Butterworth_JE, Hays_R, McDonagh_STJ, Richards_SH, Bower_P, Campbell_J. Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations. Cochrane Database of Systematic Reviews 2019, Issue 10. Art. No.: CD013124. DOI: 10.1002/14651858.CD013124.pub2 .
A career in general practice provides a myriad of opportunities for young and aspiring GPs. The core work as a generalist of providing holistic, patient-centred care to our patients ‘from the cradle to the grave’ and establishing continuity of care with our patients over a long period of time is truly rewarding. GPs can also lend their unique skill sets to other elements of primary care to improve the health of our patients and our community. Developing and building a GP practice or practices through partnership, commissioning NHS services as part of a CCG, and teaching the next generation of GPs are all possibilities open to early career GPs. Academic general practice, contributing to the improvement of primary care through research, is another vital area that GPs can turn their hand to.
But where to start? And how?
First5 GPs and GP trainees are busy people. As GPs we are trained to be lifelong learners, and there is a steep learning curve to begin with in transferring from hospital to community care. Newly qualified GPs need time to find their feet. Some opportunities exist for formal academic training through academic foundation posts in primary care departments, academic clinical fellowships for trainees, and in-practice fellowships for GPs, but these posts are very competitive and require commitment to an academic career. Opportunities to ‘dip one’s toe in the water’ in primary care research are harder to find.
Trainee research collaboratives
A successful model for trainee-led research, audit and quality improvement that has been used by other medical specialties in recent years is that of trainee research collaboratives. These local, regional and national groups exploit the networks of hospital specialty trainees across multiple sites to conduct research and audit projects. The advantages of this approach are that patients can be recruited and data can be quickly and cheaply collected across a number of centres(1). For doctors involved, they can engage in the process on many levels, from identifying patients or collecting data at their local site right through to developing and proposing new ideas for research, audit or quality improvement projects. They can also develop their teamwork, leadership and communication skills(2). Medics without any research experience have the opportunity to gain an insight into how studies are conducted, and their eyes may just be opened to the world of academia.
Trainee research collaboratives in the UK have rapidly expanded in some disciplines in the last 10-15 years. Surgery and anaesthetics in particular have a number of established regional research collaboratives and networks, including the Severn and Peninsula Audit and Research Collaborative for Surgeons (SPARCS) and the South West Anaesthesia Research Matrix (SWARM) in the south west of England. Between 2012 and 2016, the proportion of general surgery units across the UK which participated in at least one study run by trainee research collaboratives grew from 44% to 99%(3). Numerous randomised controlled trials and national audits have been delivered by these collaboratives, resulting in truly impactful research that is improving patient care(4).
PACT – Primary care Academic Collaborative for Trainees
General practice is ideally placed to take full advantage of the trainee research collaborative model. GP trainees are embedded in GP surgeries in all parts of the UK and cover all sections of the population. Electronic medical records can easily be searched for patients who meet inclusion criteria for research and audit, and the general practice model means changes arising from quality improvement projects can more easily be implemented at a local level. General practice in the UK is moving towards networks and federations of practices, making engagement in a collaborative a great opportunity for GP trainees and First5 GPs to experience working with colleagues across multiple GP surgeries towards a common goal.
The Primary care Academic Collaborative for Trainees (PACT) was launched by its chair, Dr Polly Duncan from the Centre for Academic Primary Care in Bristol, at the recent National GP ACF and early career researcher conference in Manchester. We have established a core committee of GP trainees and First5 GPs from right across the UK, and we will be coming to the 48th SAPC Annual Scientific Meeting in Exeter in July to deliver a workshop to develop the very first collaborative project PACT will undertake. PACT will generate numerous opportunities for GP trainees and First5 GPs to bring forward their ideas, and will seek to support them in delivering these projects to improve care for our patients across the UK.
Dr Sam Merriel GP and Clinical Senior Research Fellow, University of Exeter
Vice chair, PACT – Primary care Academic Collaborative for Trainees
Kasivisvanathan V, Kutikov A, Manning TG, McGrath J, Resnick MJ, Sedelaar JPM, et al. Safeguarding the Future of Urological Research and Delivery of Clinical Excellence by Harnessing the Power of Youth to Spearhead Urological Research. Eur Urol [Internet]. 2018;73(5):645–7. Available from: https://doi.org/10.1016/j.eururo.2017.10.026
Kasivisvanathan V, Ahmed H, Cashman S, Challacombe B, Emberton M, Gao C, et al. The British Urology Researchers in Surgical Training (BURST) Research Collaborative: an alternative research model for carrying out large scale multi-centre urological studies. BJU Int. 2018;121(1):6–11.
Nepogodiev D, Chapman SJ, Kolias AG, Fitzgerald JE, Lee M, Blencowe NS. The effect of trainee research collaboratives in the UK. Lancet Gastroenterol Hepatol. 2017;2(4):247–8.
Jamjoom AAB, Phan PNH, Hutchinson PJ, Kolias AG. Surgical trainee research collaboratives in the UK: An observational study of research activity and publication productivity. BMJ Open. 2016;6:e010374.
Over a third of all patient visits with a general practitioner are estimated to involve a mental health component, and 90% of these patients are primarily managed in primary
care . Due to this high demand, National Institute of Health and Care Excellence (NICE) guidelines recommend the provision of computerised CBT as an initial lower intensity treatment for depression in primary care . Computerised CBT is more accessible, scalable and cheaper than face-to-face CBT and has the potential to reduce the burden of depression in primary care significantly.
Systematic reviews have confirmed the effectiveness of computerised CBT . However, a randomised controlled trial published in the British Medical Journal in 2015 reported that supported computerised CBT did not improve depression outcomes compared with usual GP care alone . On the back of this, the authors suggested that the routine promotion and commissioning of computerised CBT be reconsidered. I would caution against this for the following reasons:
First, it is unlikely that computerised CBT will reduce depression if patients do not adequately use the platform or actively engage with the cognitive and behavioural techniques offline in their day-to-day lives. The median number of online sessions completed by patients in the study by Gilbody et al. ranged from 1–2, and no data were reported concerning offline engagement. Were the negative findings due to an ineffective intervention or the lack of engagement?
Second, a large proportion of participants across all arms of the trial were using antidepressants (81%). It is therefore unsurprising that the trial failed to find a positive effect. The argument for computerised CBT is not that is will be more effective than usual care, but that it offers a viable alternative that takes the pressure off general practice and offers patients another treatment option that is less resource intensive.
The issues in the study by Gilbody et al. are by no means unique and are indeed prevalent across the field of computerised interventions for mental health. However, resolving these issues are fundamental to ensure we don’t prematurely reject interventions with the capacity to transform healthcare. As highlighted by the NHS -term plan, harnessing the power of technology and empowering people to take responsibility for managing their own health is vital to meet the increasing demand on healthcare services. This is well within our grasp, but we need to be asking the right questions!
Ferenchick EK, Ramanuj P, Pincus HA. Depression in primary care : part 1 — screening and diagnosis. Br Med J. 2019;
National Institute for Health and Clinical Excellence. Depression in adults: recognition and management. 2018.
Karyotaki E, Riper H, Twisk J, Hoogendoorn A, Kleiboer A, Mira A, et al. Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data. JAMA Psychiatry. 2017;74(4):351–9.
Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, et al. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015; 1–13.
We know that about 10,000 UK cancer deaths a year would not occur if the UK performed as well as its European counterparts in diagnosing cancer early. Much of the problem lies in General Practice – it’s very difficult to identify the patient who may have a cancer explaining their symptoms. There has been a lot of important work conducted by Prof Willie Hamilton and his colleagues who have identified which symptoms of possible cancer actually matter. These studies have led to the development of Risk Assessment Tools (generally abbreviated to RATs). The RATs tell GPs what the patients’ risk of having a possible cancer is and is reported as a percentage. This figure can be calculated for single symptoms (e.g. the risk of cancer of the lung with coughing blood is 2.4%), as pairs of symptoms (coughing blood accompanied by loss of weight is 9.2%) or as repeated symptoms (a re-attendance with coughing blood is 17%). RATs have been developed for 18 different types of cancer and have been given to all UK GPs practices in either paper, mouse mat, calendar, or web-based forms. RATs are useful but are perhaps not immediately accessible to GPs – a GP needs to be thinking about possible cancer and needs to have to the tools to hand to see what a patient’s risk of cancer is.
Recognising this problem, RATs have subsequently evolved. In partnership with Macmillan, the UK cancer charity, electronic versions for seven major cancers (lung, colorectal, pancreas, oesophago-gastric, bladder, kidney and ovarian) have been developed. These eRATs will be integrated into GPs’ clinical software. Using information in patient’s medical records the eRATs automatically prompt the GP when the risk of one or more of these cancers is above 2%. This is an important improvement on the RATs – GPs will be alerted to the small possibility of cancer when they perhaps were not considering it.
The big question that we need to ask ourselves is do these eRATs work? Will they help us catch cancer sooner? Here, in Exeter, led by Prof Willie Hamilton, our team of experts in cancer diagnostics, general practice, health economics, and many other areas are trying to answer this important question. We will do this via a large trial, a trial we are calling ERICA.
We are looking to recruit 530 practices across England. Half of the practices will be given access to the eRATs and half will not. Practices will be in the trial for about 2 years and out of all the patients diagnosed with cancer during this time we will be looking at the stage of the cancer that they are diagnosed with (early vs. late stage). If the eRATs help GPs we might expect to see an increase in early (vs late) cancer stage diagnosis for patients from practices who used the eRATs compared to the practices who did not use them. The study will also explore other important issues such as how the eRATs impact on patients’ and GPs’ experience of care. We will also look at how the eRATs impact NHS costs and the downstream consequences on NHS services.
This trial represents a significant piece of work – it will be the largest trial of cancer diagnostics in general practice in the UK. This trial has only been made possible via a very generous donation of £2m from the Dennis & Mireille Gillings Foundation. It is also being financially supported by Exeter University and Cancer Research UK.
Oh, and my job? I’m responsible for ensuring that we get the trial done on time and within budget. It’s going to be a fantastic challenge and I’m relishing the prospect of supporting our wonderful team to deliver this vital piece of research. We start recruiting practices in summer 2019. Although we won’t have definitive findings until autumn 2023, please do come back to me to get an update on how we’re doing…
Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study. Thorax. 2005;60(12):1059-65.
Hamilton W, Peters TJ, Bankhead C, Sharp D. Risk of ovarian cancer in women with symptoms in primary care: population based case-control study. BMJ. 2009;339:b2998.
Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. Br J Cancer. 2009;101 Suppl 2:S80-6.
Hamilton W, Round A, Sharp D, Peters TJ. Clinical features of colorectal cancer before diagnosis: a population-based case-control study. Br J Cancer. 2005;93(4):399-405.
Shephard E, Neal R, Rose P, Walter F, Hamilton WT. Clinical features of kidney cancer in primary care: a case-control study using primary care records. Br J Gen Pract. 2013;63(609):e250-5.
Shephard EA, Stapley S, Neal RD, Rose P, Walter FM, Hamilton WT. Clinical features of bladder cancer in primary care. Br J Gen Pract. 2012;62(602):e598-604.
Stapley S, Peters TJ, Neal RD, Rose PW, Walter FM, Hamilton W. The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case-control study using electronic records. Br J Cancer. 2013;108(1):25-31.
This post is a year late. Mainly, this is due to the many, louder tasks on my Primary Care research to-do list: delivering our final report on the NIHR ReGROUP GP workforce project, writing and submitting further papers from ReGROUP (see below) completing two rapid-fire projects for RCGP on mapping UK and international GP training, attending conferences of the Society for Academic Primary Care (plug: Exeter hosting next year!) and working up two major NIHR funding bids… A busy year.
Nevertheless, the UK’s GP workforce ‘crisis’ has by no means gone away, and here’s some new research findings for you.
Last summer, we surveyed our local GP registrars at the end of their specialty training, as they were ready to move into the workforce. With the help of Health Education England, we surveyed 81 trainees in the South West Peninsula region. Forty five responded (55.5%): 40% male, 60% female, mean age 35.7 years, majority white British and obtained their primary medical qualification from the UK/Ireland:
82.2% (37) intended to move straight into GP-based patient care.
9% (4) intended to take a career break first but then return to GP-based patient care, and one trainee intended to take a career break but ‘may not’ return.
A further 6.7% (3) intended to move on to ‘something else’.
Among the 42 intending to, or who may, move into GP work (initial career breaks aside):
The majority (28 [66.7%]) planned to work part-time in the long-term, with just 6 (14%) planning to work full-time, and seven (16.7%) who were undecided.
Most (32 [76.2%]) had already secured a GP-based clinical post from August 2017. Thirty of these 32 trainees (93.7%) would be working in the South West, and two outside of the UK (one in Europe, the other outside of Europe).
Most (34 [81%]) knew what position they would take up: four working as GP partners (9.5%), 18 as salaried GPs (43%), and 12 as locum GPs (28.6%). Three did not know what their role would be and a further five reported an ‘other’ position, including GP retainer and continuing as a GP trainee/registrar.
Portfolio working was a popular aim, with many interested in medical education (25 [60%]), three in research (7%), and eight in non-GP clinical work such as sports medicine (19%).
Many (24 [57%]) anticipated being involved in delivering out-of-hours care: nine with regular sessions, 15 with occasional sessions.
Morale was reported as high or very high by 16 (43%). Twenty reported morale as neither low nor high (47.6%), and four as low (9.5%).
A small number already knew that they were likely or very likely to permanently leave GP: three within two years (7%), and four within five years (9%).
It was a small survey and we conducted it a little last minute. But despite taking a year to write about it, the questions remain important to ask.
So, why did we do this? In part, it was because we saw Health Education England publish a similar small survey on the London trainees last summer, and it was also because we are genuinely interested in this. Current GP trainees are the imminent future of the GP workforce, an agenda that we’ve supported with our Exeter research over the last four years.
GPs do a difficult job; they manage a high (rising) and complex workload due to the ageing population and more patients having multimorbidity. Add this to decreased NHS spend on Primary Care and resources for general practice and continually changing care models – GPs are leaving, or decreasing their working hours, in large numbers. Our own survey of South West GPs indicated that 37% were highly likely to quit patient care within five years, a worryingly high figure that is in line with the most recent national figure of 39% from the GP Worklife Survey, and other similar survey findings reported elsewhere in the UK in recent years.
Efforts are focused on both recruitment and retention, across all stages of the workforce ‘pipeline’. Immediate retention of our existing GPs remains essential, and is something we have worked hard to support with our NIHR ReGROUP project. Recruitment to, and growth of, GP training places is equally critical. The government’s target is to recruit 5,000 extra GPs and train over 15,000 GPs by 2020, as well as recruiting 2,000 overseas doctors over the next three years.
It is generally already known what sorts of specialties medical students and graduates want to pursue in their long-term careers: GP is still the most popular first choice, but this is showing a downward trend in recent years compared with other specialties and the percentage of medical graduates preferring GP remains lower than the proportion required to meet workforce needs. We also know about the choices made by Foundation doctors, through the Careers Destination report published by the Foundation Programme. Again, GP specialty training is top of the list and recent growth of training places and record fill rates reported by Health Education England this year after only Round 1 all shows promising progress against government targets.
But why is it important to know what GP registrars plan to do with their careers once they qualify? Surely, they have already been successfully recruited to GP specialty training and have completed the three years of training, spending huge resources gathering the required skills and experience and delivering front-line patient care in general practice?
It matters because we must be alert to the brand new GPs who do not go on to work in a GP job, or who do so on a much reduced basis. And, alarmingly, some of those that qualify are already thinking of permanently leaving GP in the not-distant future. Training a GP all the way from medical school and through specialty training costs just under half a million pounds. If our GP registrars are not moving into the workforce once they qualify, we lose vital and expensive resource.
Something seems to be happening during training. Trainees are being exposed to the issues faced by our current working GPs and that are outlined very clearly in the Wass report. Our (very small and regional) survey adds in a small way to the picture that a percentage of trainees may be lost to the workforce in some way such that growth of training places and recruitment efforts alone will never keep up. Even in the lovely South West where the sun always shines and the surf’s always up.
More work is needed to continue to improve the attractiveness of general practice and address its challenges; progress is being made in some areas but only time will really tell.
With thanks to all of the South West Peninsula GP registrars who completed our last-minute online survey last summer!
, Research Fellow
References from Primary Care Group
Campbell J, Calitri R, Sansom A. Retaining the experienced GP workforce in direct patient care (ReGROUP)- final report. Exeter: University of Exeter Medical School; 2015.
Campbell JL, Fletcher E, Abel G, Anderson R, Chilvers R, Dean SG, et al. The changing general practitioner workforce: the development of policies and strategies aimed at retaining experienced GPs in direct patient care (ReGROUP) NIHR HSDR 2019 (full ref to be assigned). In: National Institute for Health Research (HS&DR); 2019 (in press, draft available from authors).
Fletcher E, Abel GA, Anderson R, Richards SH, Salisbury C, Dean SG, et al. Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners. BMJ Open 2017;7.
Sansom A, Terry R, Fletcher E, Salisbury C, Long L, Richards SH, et al. Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England. BMJ Open 2018;8.
Spooner S, Fletcher E, Anderson C, Campbell JL. The GP workforce pipeline: increasing the flow and plugging the leaks. British Journal of General Practice 2018;68:245.
The Health Services & Policy Research Group hosted two summer interns from the BMedSci programme again this year. They actively contributed to ongoing work and were valued highly within the team. They have both since reported that:
“My 4-week placement with the Health Services & Policy Research Group has been invaluable, exposing me to research and providing a plethora of opportunities to gain crucial techniques and skills that will carry forward not only throughout my undergraduate studies but also to take into the world beyond BSc Medical Sciences. Through working on a scoping review into healthcare system performance for patients with multimorbidity I learned the key differences between scoping reviews systematic reviews, learnt how to perform complex searches in databases, which had previously intimidated me during my undergraduate studies, and helped to screen at text-level, learning the useful ability to read things quickly but thoroughly! I felt incredibly welcomed amongst the team; rather than feeling like a work experience student making tea, I felt fully part of the group, attending meetings and lectures, and learnt a lot by being thrown in at the deep end. I am delighted I have had this wonderful opportunity, gained a wide range of experience, and met brilliant people, and I’d like to thank everyone who made it so great.”
“Being part of a research team focusing on Patient Reported Outcome Measures (PROMs) is a great opportunity for me as a first year medical sciences student. Learning about the diseases in lectures is one thing, but hearing it from a patient’s perspective as to how it affects them is another. The purpose of the study I was part of was to see how chronobiology played a role in the symptoms of the people suffering from multimorbidity. This was specifically narrowed down to people suffering from a combination of asthma, osteoarthritis or depression. Through this, GPs may have a better understanding on how different people express symptoms over the day or year and possibly advise them on when would be a better time for them to take the medication. Based on the results of the questionnaires and the interviews, there are slight variations of symptoms being experienced over the day and seasons. For example, people with osteoarthritis tend to have more pain towards the evenings and people with asthma tend to have a flare up of symptoms when the pollen count is high during the summer. This has also provided a good insight for patients as some may have not noticed a variation in their symptoms before and from this they might be able to better manage their conditions.
It has been pleasurable working with a research team who have been very welcoming to me since my first day which made my experience here even more beneficial. During my placement, I have learned how to input quantitative data into a statistics program called Stata. I have some understanding as to how bids are placed and the process behind it. My time in this placement has definitely sparked my interest in pursuing a career in this field of research.”
Happy Birthday #NHS70 – an amazing Institution harnessing clinical, organisational, academic and management skills for the benefit of patients and the public. Right at the heart of the NHS is General Practice – the clinical specialty provided by 40,000 GPs and their teams, and delivering care at the front-end of the NHS. GPs are by their nature, disposition, training, and clinical practice, generalists in clinical medicine. GPs provide care that is coordinated, continuous and comprehensive, with many GPs having a long and valued relationship with individual patients and their families. They have central roles in the prevention, diagnosis, management, and follow-up of virtually all conditions for which a patient might seek medical help or advice. They and their teams care for over a million patients every working day – what a great job!
Our research centres on the organisation and delivery of primary medical care in the UK, with a particular focus on access to care, alternatives to face-to-face consultations, the quality of care and the quality of patients’ experience of care, and the safety of primary care provision. Have a look here for a comprehensive summary of our work on patient experience – or you can find it in the 40 papers we’ve published on the subject in the past few years! Within APEx we have five great research groups, all delivering brilliant, patient-focused research. Here’s some examples!:
The Primary Care Research Group have recently undertaken and reported important research identifying major problems in relation to the capacity of the GP workforce, and proposed many solutions which are currently under consideration by key health institutions and authorities in the UK.
Patient and policy-focused research including the use of patient reported outcomes and the key issue of new models of care, especially models which are relevant to an ageing multimorbid population
We deliver top-quality research in key areas of clinical care that are of direct importance to patients:
Case Study – Monitoring and Managing Patients’ Experience of Primary Care
We’ve worked with colleagues in the University of Cambridge over the past ten years to develop, and to undertake research in respect of patients’ experience of primary care. These researchers were involved in working with the NHS and with IPSOS Mori in designing the national GP Patient Survey. This survey instrument is now routinely used across all of primary care in England (7800 practices) and the resulting data provides an important overview of patients’ experience of primary care by English general practices. For example, have a look at myNHS where you can see patient experience data for all practices in England. The resulting data also forms the basis of much of the date used by the Care Quality Commission in their inspection of general practices. In previous years, GPs and their practice teams have been rewarded for both taking part in monitoring patients’ experience of care, and, at some points, for providing high quality patient experience. Such arrangements have now changed, but the GP Patient Survey remains central to the monitoring and delivery of primary care in England.
So, Primary Care research matters! It would be a long blog if I tried to cover all our interests, and we’re part of a much wider community of Primary Care Academics who are delivering great primary care research and education across all of the UK.
Thanks for having a look at this – keep in contact! We’ve got a great team here in Exeter and we’re always happy to let you know what we’re up to. We’re supporting the NHS for the next 70 years!
Professor of General Practice and Primary Care and Director, APEx
Hi, my name is Dr Phil Evans and I have been working in the NHS for exactly half of its lifetime, and well over half of mine! Of the 70 years since the NHS was formed, I have been working for 35 of them as a doctor and I have recently retired as a GP partner after 30 years in the same practice in Exeter. The NHS has given me a wonderfully stimulating and exciting career. In my opinion, general practice really is the jewel in the crown of the NHS but nevertheless is often under-valued, as are the skills and attributes of its hard-working GPs.
The NHS has given me an amazing opportunity to practise what I preach in terms of promoting continuity of care with the same doctor and the ability to get to know patients and their families, sometimes up to four generations of a single family, over a long period of time. The phrase “from cradle to grave” sums up the whole of general practice. The privilege of meeting patients week after week, year after year and trying to address their changing medical, psychological and social concerns is at the heart of what we do. Each consultation is still however a trip from the known into the unknown.
The partnership model in NHS general practice has allowed me, as a GP partner, not just to see patients but to run our own practice as an organisation that provides high quality medical care in a way that we wished. We could invest in our practice to value patients, promote patient-centred care, but also promote the other attributes that are close to my heart, teaching and research.
The NHS has given me the opportunity to undertake my own research and gain a higher degree in the process, working in our practice to answer important research questions. More recently I have been fortunate to work with other researchers in universities and across the NHS in my national role in the Clinical Research Network (CRN) to promote research and embed research in everyday practice. The CRN is an integral part of the NHS and runs research studies across all parts of the NHS, including general practices. Other countries are very envious of the NHS and its research!
The traditional model of GP working which I have so much appreciated is threatened in the NHS changes when “bigger is better” as far as practices are concerned and there is an emphasis on speed of access rather than developing deeper relationships with patients. We are, in my opinion likely to “throw the baby out with the bathwater” if we don’t value continuity and all its proven advantages – many of which I have experienced as a doctor. We must find ways in the NHS to value continuity, firstly by measuring it, then promoting and incentivising it.
So having worked in the NHS for half of its life it has been a privilege, but I worry that the things I value as GP are now threatened as the NHS moves into its next decade.
Associate Professor in General Practice & Primary Care
What the NHS means to me As a GP in the NHS, I feel proud to be part of one of the largest and most impressive work forces in the world, particularly when its aim is to provide good quality healthcare for all patients in the UK, regardless of their wealth. I am also a user of this service that covers everything; from routine health screening, to antenatal checks, emergency healthcare, management of long-term conditions and end-of-life care. As one of over a million patients accessing NHS care in a 36 hour period, I felt safe and provided for; as a new mother on a hospital ward, and later at home with my community midwife.
In addition, I contribute to primary care research and to education within the NHS. Along with over 200 academic GPs in the UK, I aim to provide guidance, through research and evidence, for the future development and organisation of the UK health service. I teach, and I promote lifelong learning, to ensure a competent and confident workforce; from the medical student, to the junior doctor, to the fully-fledged GP.
What is the role of primary care within the NHS? Primary care is known as the “front door” of the NHS as it is the first point of contact for most NHS patients. It is delivered by GPs, dentists, pharmacists, optometrists, NHS walk-in centres and the NHS 111 phone service. A whopping three hundred million consultations take place in General Practice each year. Whilst patients are generally satisfied with the care that they receive, it is often difficult to access a GP. The “front door” is not always as open as we would like.
What has changed in primary care in my career? I qualified as a doctor in 2007 and completed my GP training in 2013. Over the last ten years I have witnessed significant restructuring of the NHS and ongoing reform of primary care services. Of note to me as a newly qualified GP, clinical commissioning groups replaced primary care trusts, with the aim of enabling clinicians to lead on the planning and commissioning of healthcare services for their local area. Many GP practices are merging with the aim of sharing knowledge and resources. However, funding for hospital services has been increasing at twice the rate of funding for general practice services and we are seeing more and more privatisation of health services. NHS staff have become demoralised; junior doctors are leaving to work abroad, senior doctors are taking early retirement and we are currently in the midst of a GP workforce crisis.
What needs to change in the future? As the population grows, so too will the number of older patients with multiple health problems and these patients are known to consult frequently. This will put incredible strain on the NHS and we will need to be financially ready to cope with it. Patients and their carers should be involved in making decisions about their healthcare and the services that are commissioned. Healthcare needs to be patient-centred and individualised. We need to seek ways to enable continuity of care with the same healthcare practitioner and longer consultations for our most vulnerable patients.
In order to increase positivity amongst the GP workforce the workload needs to be made more manageable. However, consideration should be given to the wellbeing of GPs, and that of other healthcare practitioners, when restructuring and delivering new health services for patients.
We need to encourage more medical students, along with nursing, pharmacy, physiotherapy and occupational therapy students, into careers in primary care. We need to use their skill-sets flexibly, and in a close-knit multidisciplinary unit, to provide high quality but cost-effective healthcare. We should give undergraduates the skills to manage the uncertainties that they will inevitably face once qualified, and encourage them to become health service pioneers and leaders. We should invite them to problem-solve, look beyond guidelines and question evidence, to work cohesively with their colleagues in secondary care, and to embrace the challenge that is the future of the NHS.
My decision to aim for medicine
The NHS is undoubtedly a source of great pride in this country. The fact that anyone can book into any of the 7,000 GP practices (or 168 acute trusts) in this country and receive top quality care for free is surely one of our greatest achievements. There is a strong argument to spend more on the NHS, as the UK spend less as a proportion of GDP than comparable countries, but that we have been able to achieve this level of access is quite incredible.
That being said, we are a nation of complainers, and the NHS receives more than its fair share of groans, eye rolls, and tut-tut-tuts. I often find myself defending the NHS against these (often totally justified) complaints, because I feel like a real part of the system, and truly believe the NHS to be a national treasure. Perhaps this is part of what first attracted me to a career in medicine.
From my (admittedly limited) experience of working around doctors of all specialties and grades, it is evident that medicine is an arduous job, with long unsociable hours, high pressure, low levels of flexibility and literal life-and-death situations on an almost daily basis for some. This is something that everyone entering this noble career needs to understand; it isn’t all running around with defibrillator paddles shouting “Clear!” and shocking people back to life. It isn’t all chest compressions, medical mysteries, and slow-motion moments either. Medicine is a stressful, difficult, and often frustrating career, and it certainly isn’t for everyone.
For me, this was always vastly overshadowed by the positives of this career. I felt that working with people in what can be the most difficult time of their lives, opportunities for leadership, the requirement for lifelong learning, and the clear career progression (not forgetting the more-than-comfortable salary of course) were all strong enough reasons to look past the angry drunks in A&E, the nights on Geriatrics, and the screaming in Paediatrics. Thankfully I am still of this opinion now and, if anything, am even more confident that I made the right choice when I embarked on this professional journey.
What does the NHS mean to me?
The NHS is much more to me than a network of trusts, deaneries, CCGs and administration teams. It is more than an interconnected web of doctors, nurses, porters, cleaners, ODPs, HCAs, and secretaries, too. It is a symbol of a national ideal that I feel is often lost in the name of ‘strengthening the economy’, ‘encouraging competition’, and ‘streamlining services’: the notion that everyone, no matter their background or income, is entitled to care for their entire life without having to worry about finding the money to pay for it. This basic right, so often taken for granted in the UK, is absolutely fundamental as we strive for equality and justice in this country. The success of the NHS flies in the face of the laissez-faire attitudes of some people in this country, and shows that what we can achieve together is vastly greater than what we can achieve on our own. The progression towards a fair society begins, I believe, with seeing just how powerful a force the united peoples of this country can be. Establishing the premise that everyone deserves to be treated fairly, regardless of their income or background is the first step in achieving true equality, and it is this idea that, for me, the NHS embodies perfectly.
My hopes for a career in the NHS
Like many people in my cohort, I can see my career in the NHS taking a tortuous route. I currently feel that some part of acute medicine is where I want to be – be that A&E, MAU, ICU, anaesthetics etc, but I am certain that I won’t be going straight through a training pathway into a consultancy post as people often felt they had to before. I have always had an interest in medical education, which has only been reinforced by the Masters in Clinical Education I have undertaken this year, and definitely feel this will form a part of my career. I also hope to conduct research alongside my clinical work, and aim to complete a PGCert in Clinical Trials alongside my fifth-year study to further this aim. I am also currently in the latter stages of an application to become a Magistrate, and feel that volunteering and working outside the NHS is important for maintaining morale and avoiding burnout. Finally, I see no reason why I shouldn’t change careers as I progress through life. While the fast pace and more antisocial hours of acute medicine appeal to me now, I have enjoyed my time in primary care so far and would like to consider this as an option as my career and life progress.. I essentially want to have my fingers in as many pies as possible. After all, variety is the spice of life!
My concerns about working in the NHS
My main concern about entering a career in the NHS is that it may not exist by the time I retire. Even within the few years during which I have been conscious of these things, I have seen a gradual effacement of the NHS at the hands of various government and private companies. This of course did not start recently, and goes back in my opinion to the hallowed Blair years of extremely high spending but also privatisations and PFIs. Today, despite the recent announcement of a £20bn funding boost, the NHS remains chronically deplete of money. My worry is that this is part of a concerted effort to devalue and destabilise the NHS so it can be increasingly moved into the private sector – being as it is totally antithetical to the belief that the state should hold as small a role in the lives of working people. Perhaps this is why I argue so vehemently against those who moan about the NHS, as every disillusioned voter is another step towards the end of the NHS.
The NHS I would like to be looking back on
I hope that, at the end of my career, I can look back on an NHS that has not only continued to lead the world in terms of efficiency but has improved outcomes to a world leading level and that has also grown to absorb more aspects of healthcare. Why do we complain about 2 month waits for non-emergency surgery, yet tolerate 2 year waits for dentist lists? Why do we accept a £15 charge to visit an optician, while begrudgingly paying an £8 prescription charge for drugs that would otherwise cost £30?
I believe the NHS will once again be an organisation that can claim to truly support people from cradle to grave, but first we have to ensure that we see its true value, not only as a collection of buildings and workers, but as a bastion of unity, togetherness, and equality unparalleled anywhere in the world.