Do we need academic primary care?

A few weeks ago I took part in a debate in which I attempted to defend the motion,

“THIS HOUSE BELIEVES THAT THE FUTURE QUALITY OF NHS CARE DEPENDS ON BUILDING A STRONGER FOUNDATION OF ACADEMIC PRIMARY CARE”.

I enjoy debating and public speaking and accepted the invitation to speak without hesitation. As the day of the debate approached I grew increasingly apprehensive and unsure that I could convince myself, much less anybody else that I believed what I was supposed to say. When my turn came to speak I froze, I could barely speak, my heart pounded, I stumbled over words and phrases and I panicked and prayed for the ground to swallow me up. I’ve had a handful of panic attacks in my life, usually related to getting lost or driving, but this was the most public. It was awful.

And so with this still in mind, I attended the Society for Academic Primay Care Annual Scientific Meeting SAPCASM hoping to be inspired and convinced of the motion I had failed to defend.

The conference began for me with a session about becoming an independent researcher. Working in small groups we thought about how to sell our research ideas to an enlightened philanthropist (Bill Gates). It forced us to think about why our research mattered and why we were the best people to be doing it. An overarching theme was that young researchers are often not good at selling our ideas, much less ourselves and we need to practice this. I left wondering whether it was more about a good act than a good idea.

The first plenary from Frank Sullivan was about whether antivirals should be used in the treatment of Bell’s Palsy. Early in his presentation he told us that even though we have known for years that steroids are effective (NNT=9) they are only prescribed in 50% of eligible cases. If there was a meta-theme to the conference it was this – why are we researching new avenues (like antivirals, which by the way, don’t work) when what we already know to be effective is not yet done routinely? Why isn’t that the major focus of academic primary care?

My poster was up for the first session. I spent the full 25 minutes listening to an enthusiastic delegate and barely had time to talk about it to anyone else. Then I had to take it down. A few hours work and £18 printing costs for what?

In the next session I learned that patients don’t like to criticise their doctors too much. Of course, I didn’t learn that there, because as a GP, this has been obvious for as long as I’ve been in practice, and is obvious to most patients too.  The question, ‘what do we need reliable measures of patient satisfaction for?’ Is a good one and whether you want to help me be a better GP, or turn patients into consumers will probably influence the measures you use. I lamented the lack of politics here.

I was fortunate to see a prize-winning systematic review of GP recruitment strategies from Puja Verma. If only Jeremy Hunt and the RCGP had seen it too. The only thing that works is to change undergraduate education. Keele have got it right, Oxford has got it wrong and there’s not a snowman’s hope in hell that we’re going to get the 5000 extra GPs the government have promised in the time required.

Head of NHS England, Simon Stevens gave the afternoon plenary. He said he wants to make primary care more multi-disciplinary, offer more alternatives to face-to-face consultations and nurture diversity of primary care provision. It was as if he had read my blog for the Centre for Health and the Public Interest. The problem is that I don’t think he realises how efficient GPs are. For almost 40 consecutive face to face consultations I documented who else could have seen my patients. Typically, instead of seeing me (a doctor they knew) they could have seen 2 or 3 other people such as a pharmacist, psychologist, physiotherapist, nurse practitioner or nursing assistant. But instead, in 10-12 minutes I was able to review their medication, listen to how they were coping, take a look at their arthritic hands, inject their thumb and give them an information leaflet. Despite what I wrote in the blog, I think his ideas will mostly lead to higher costs, more fragmentation and loss of continuity. Patients who can manage remote consulting should be enabled to do so, and this might free up time for those who cannot, but we need more GPs! And policy makers should read The Mystery of General Practice to help them understand what we do.

Katherine Yon gave a presentation and Rona Moss-Morris gave a keynote about Medically Unexplained Symptoms, perhaps better described as ‘persistent physical symptoms’. Doctors, educators and medical students are all afraid of what they don’t (and probably cannot) know, and so they tend to avoid it. Only 6 out of 53 medical schools provide training on MUS even though MUS accounts for 18% of GP workload and up to 50% of out patient workload. Most GPs will tell you that an enduring theraputic relationship is vital and most patients will accept that stress can cause physical symptoms, if assured that their symptoms are not imagined. There is evidence that some medical students avoid general practice on the grounds that it is not intellectually challenging enough. Medically unexplained symptoms and the patients who suffer them are as challenging as medicine gets, but it is a human challenge as much as an intellectual one and we might do well to celebrate the human challenges of general practice as one of its greatest attractions.

Christine Cabral gave a presentation about communicating with parents of children with a respiratory tract infection. When I summarised some of the qualitative literature last year, I came to the conclusion that parents wanted confidence, not reassurance. We need to do more to reassure parents that their concern is appropriate and then give them the confidence to cope after the consultation. Carol Sinnot, who presented some wonderful work on multimorbidity suggested I did a study to look at whether giving confidence reduced re-consultation rates. For a while I thought this was a good idea, but on reflection I thought, why not just do it because it’s the right thing to do?

There was a lot about multimorbidity including Bruce Guthrie’s wonderful plenary, ‘Multimorbidity: New paradigm or emperor’s new clothes?’ We learned that the main determinant is deprivation: people in the poorest areas have the equivalent health of people 15 years older in the wealthiest areas and the most debilitating morbidities are depression and chronic pain. This is most of what I deal with as a GP in one of the most deprived parts of Hackney. What do we need? Time and continuity of care in part, but most of all we need political action on the social determinants of health! Why isn’t there more political advocacy from academic primary care? So much downstream research and so little upstream action.

There were a range of papers about patient-centred practice and patient involvement, but as far as I could tell, no actual patient involvement, except for the fact that in one way or another we were all actual or potential patients. It is worth noting that many primary care researchers are not clinicians. But most primary care research is published in pay-walled journals and out of reach of the average (or even above average) patient or non-academic GP. This is a problem. I try on my blog to share research in a way that makes sense for these audiences, but this isn’t academic research and so won’t do anything for an academic career.

One of the best presentations of the conference was from Lesley Wye from Bristol about ‘Evidence based policy making and the art of commissioning’. This ethnographic study looked at how commissioners used evidence when making decisions. Unlike researchers who like to read and write, commissioners are social animals who like to stroll across the office and ask a colleague. Commissioners view ‘evidence’ as hard to find, hard to interpret, hard to apply and too slow. They tend to think that evidence is for healthcare but not commissioning. Researchers need to work with commissioners in the same space. Lesley’s work – undertaken with Chris Salisbury reminded me of the other highlight of the conference, a workshop on co-creation in research from Claire Jackson, Trish Greenhalgh and Judith Smith. Their message was that co-creating research takes place in the swampy lowlands where politics and personalities collide and inevitably requires compromises between research purity and practical utility. This is where I found the inspiration I needed for my debate.