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CHAPTER What is general practice?
Career options forGPs
Times are changing in general practice. Doctors considering a life as a GP
want a more exible and varied career than in the past.
Career options within theNHS
Clinical assistant or hospital practitioner The GP works within a hospital setting on the wards or in outpatients providing a specialist service under direct
supervision of a hospital consultant. Posts are usually advertised in the medical/ GP press ± locally. Generally poorly paid.
GP with extended role (GPwER) Formerly GP with special interest (or
GPwSI). GPs who, in addition to their normal GP duties, provide a specialist
service to meet the needs of their local healthcare community:delivering
a specialist clinical service beyond the scope of normal general practice,
undertaking advanced procedures or developing services. The dierence
between a GPwER and clinical assistant is that the GPwER receives referrals from other GPs and decides on appropriate treatment independently
and not under direct supervision of a consultant, but with the support of
2° care. Posts are usually advertised to local GPs. In order to be classed as
having an extended role, GPs must:
• Have undertaken particular training in the specialty, or have a proven
track record of expertise in the specialty. Auniversal accreditation
process is currently being developed by the RCGP
• Regularly update knowledge through attendance at courses,
conferences, or meetings and through reading
• Look after a specic group of patients with the condition
• Audit practice in the specialty area demonstrating quality of care
Medical adviser or consultant in primary care Medical advisers or directors in
ambulance trusts, NHS Direct sites, etc. Some national NHS agencies have
GP advisers or directors too, e.g. National Commissioning Board. Posts are
either advertised or obtained by direct approach.
Providing GMS/ PMS ± enhanced medical services E p. 32
Providing postgraduate medical education e.g. GP tutor, GP trainer ( in 8
GPs are GP trainers), course organizer. Approach local director or dean of
postgraduate medical education.
Working for a local PCO/ CCG e.g. serving on a committee, clinical tutor, GP
appraiser, etc. Contact local PCO.
Opportunities outsidetheNHS
Academic posts AGP may be employed solely by a university or jointly by
a university and the NHS. Posts include undergraduate teachers, lecturers,
and research posts. Contact local university department or general practice
or look for posts advertised in the medical/ GP press.
Clinical sessions for commercial companies and charities e.g. school doctor for
a private school.
Complementary medicine Seek specialist training. Contact representative
bodies of the specialty chosen— E p. 128.
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CAREER OPTIONS FORGP
Forensic work e.g. police surgeon, coroner (F 020 8979 6805), expert wit-
ness (M www.ewi.org.uk).
Media work/ medical author Some sort of professional journalism qualication is useful. The BMJ oers a y registrar post for doctors with 3–
5y experience. Courses are also available through the BMA and Medical
Journalists Association (M www.mja- uk.org). If you have an idea for a
book, contact the medical commissioning editor of a reputable publisher
to discuss your ideas.
Medical adviser posts within GP and other medical organizations e.g. RCGP,
MDU, GMC. Posts may be advertised or appointments made through election or direct approach. Contact the relevant organization.
Medicals for benets Examining Medical Practitioners (EMPs) carrying out
tness to work and disability assessments on behalf of the Department for
Work and Pensions (DWP).
Medical politics GPs serve on local medical committees (LMCs) on an
elected basis. Contact the local LMC and ask about standing for election.
Work for government agencies e.g. armed forces as a civilian medical practitioner or the territorial army. Usually civilian posts are advertised in the
medical/ GP press. For commissioned posts contact service recruitment
oces.
Occupational medicine Contact: Faculty for Occupational Medicine
M www.facoccmed.ac.uk
Prison doctor Posts are usually advertised in the medical/ GP press.
Sports medicine e.g. for professional sportsmen; in private clinics. Doctors
are required to have a knowledge of sports injuries, their treatment, rehabilitation, and prevention. They also need to know about other aspects
of sport e.g. drugs in sport, nutrition, travel problems. Contact: British
Association of Sport and Exercise Medicine M www.basem.co.uk
Work abroad Contact: RCGP International Department: E- mail: inter-
national@rcgp.org.uk; RedR UK M www.redr.org.uk; Voluntary Service
Overseas M www.vso.org.uk. Overseas posts are also advertised in the
medical press.
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CHAPTER What is general practice?
Good medical practice forGPs
GMC duties ofadoctor
• Make the care of your patient your rst concern
• Protect and promote the health of patients and the public
• Provide a good standard of practice and care:
• Keep your professional knowledge and skills up to date
• Recognize and work within the limits of your competence
• Work with colleagues in the ways that best serve patients' interests
• Treat patients as individuals and respect their dignity:
• Treat patients politely and considerately
• Respect patients' right to condentiality
• Work in partnership with patients
• Listen to patients and respond to their concerns and preferences:
• Give patients the information they want or need in a way they can
understand
• Respect patients' right to reach decisions with you about their
treatment and care
• Support patients in caring for themselves to improve and maintain
their health
• Be honest and open and act with integrity:
• Act without delay if you have good reason to believe that you or a
colleague may be putting patients at risk
• Never discriminate unfairly against patients or colleagues
• Never abuse your patients' trust in you or the public's trust in the
profession
You are personally accountable for your professional practice and must
always be prepared to justify your decisions and actions.
Reproduced with permission from General Medical Council (2006), Good Medical Practice,
London:GMC. Available at www.gmc- uk.org/ guidance
Good medical practice forGPs
• Good clinical care Provide best possible clinical care for patients
• Maintaining good medical practice Monitor, review, and continuously
strive to improve performance of yourself and your practice
• Teaching and training, appraising, and assessing E p. 8
• Relationships with patients Communicate with and listen to views and
opinions of your patients; use terms/ information they can understand;
respect their privacy and dignity at all times
• Working with colleagues Ensure eective communication channels
within/ outside the practice; ensure an environment for personal/
professional development for everyone working within the practice
• Probity Behave in a proper fashion ensuring honesty and openness in all
matters. Avoid conicts between personal and professional roles.
• Health E p. 22
Source:data from Good Medical Practice for GPs (2008) www.rcgp.org.uk.
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GOOD MEDICAL PRACTICE FORGP
Continuity of care Apatient seeing the same healthcare worker over
time. In the UK this has been the norm but continuity of care is becoming
less available.
Reasons for continuity of care Apractitioner’s sense of responsibility toward
his/ her patients i with duration of relationship and number of contacts.
Continuity builds trust, creates a context for healing, and i practitioner and
patient knowledge of each other. Evidence:
• i patient and doctor satisfaction
• i compliance
• i uptake of preventive care
• better use of resources (time spent in the consultation, discriminatory
use of laboratory tests, and admission to hospitals)
Patients’ desire for personal care depends on the reason for the encounter.
Most nd it important to see their own GP for serious medical conditions
and emotional problems.
Reasons why continuity of care is becoming less available Problems balancing
accessibility, exibility, and continuity of care:
• Doctor factors GP shortages, exible careers, special interests, and
managerial responsibilities limit the availability of GPs to their patients
• Patient factors 24h society in which patients want to be seen at their
convenience rather than when their GP is available makes it impossible
to maintain continuous care. For minor problems and emergencies
patients do not mind who they see— as long as they see someone who
can deal with their problem quickly
• System factors Changing roles— nurse practitioners and other
healthcare professionals commonly take on tasks which used to be done
by GPs; clinical governance structures mean that patients with particular
conditions are managed in clinics specically for those conditions
within the practice; other primary healthcare providers, e.g. NHS ,
walk- in clinics, and separate out- of- hours cover arrangements, further
fragment care
Rationing Afull discussion on rationing healthcare is beyond the scope
of this handbook. However, with continued innovation, rising demand, and
limited resources rationing will become an increasingly important factor in
medicine worldwide. To some extent there is already rationing by default—
medicines and certain treatments are not provided via the NHS or have
very long waiting lists. Government bodies such as NICE evaluate services
and develop guidelines for healthcare professionals about medicines and
services which are both clinically and cost- eective. Inevitably, this will mean
that some groups will feel they are being deprived of the treatment they
require. It will remain a contentious issue.
Further information
Appraisal and revalidation E p. 10
GMC Duties of a doctor. M www.gmc- uk.org/ guidance/ good_ medical_
practice/ duties_ of_ a_ doctor.asp
GPC/ RCGP (2008) Good medical practice for GPs. M www.rcgp.org.uk/
policy/ rcgp/ Good_ Medical_ Practice_ for_ GPs_ July_ 2008.ashx
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CHAPTER What is general practice?
The primary healthcareteam
Shortages of GPs, i numbers of elderly patients, and a move to increasingly
specialized care being delivered in the community have changed the role of
the GP. The GP has never functioned alone, but the role of the GP as coordinator of care in the community, directing and supporting the primary
healthcare team (PHCT), has never been more important. Precise composition of PHCTs vary. Team members may include:
Practice manager General manager of the practice in liaison with the
partners. Roles include:sta appointments, supervision, training, anddismissals; duty rotas; liaison with outside organizations (e.g. PCO) and other
PHCT members (e.g. community nurses and health visitors); maintenance
of premises and equipment and nancial planning. Most practice managers
have management qualications.
Receptionists Perform an essential role as the interface between the
general public and the GPs and nursing sta. Good interpersonal skills are
essential. Training varies.
Administrative and clericalsta Perform all the non- clinical tasks
necessary to keep the practice running. Training varies.
Practicenurse Duties can vary but include ‘traditional’ nursing tasks;
health promotion; immunizations; new registration checks; specialist clinics
(e.g. asthma, DM, etc.); administration andaudit.
Nurse practitioner Specially trained nurse who takes on clinical re-
sponsibility for specic aspects of care he/ she has been trained for either
within the GP surgery or in patients’ own homes, e.g. ltering out- of- hours
calls or managing heart failure. Seen as a way to alleviate pressure on GPs.
Nurse practitioners are at least as eective as GPs in the roles they perform.
District nurse Qualied nurse who has a community nursing quali-
cation recognized by the Nursing and Midwifery Council. Most work is
conducted in patients’ homes, particularly in looking after the chronically ill
or those recently discharged from hospital. District nurses are usually employed by local community trusts or PCOs and coordinate their own team
of community nurses.
Community matron Highly experienced, senior nurse who works
closely with a limited number of patients who are high- intensity users of
health and social services (usually with serious, long- term conditions or a
complex range of conditions). The community matron acts as a ‘case manager’ and single point of access to provide, plan, and organizecare.
Health visitor Works with individuals, families, and groups in preventive
medicine, health promotion, and education. Health visitors visit all babies
after the midwife ceases to attend, carry out developmental assessment
checks, and advise on general care and immunization. Some health visitors
have a role exclusively for the elderly. Health visitors must be trained nurses
and registered as health visitors with the Nursing and Midwifery Council.
Midwife Important link between hospitals, GPs, and other members
of the PHCT in obstetric care. May practise independently when dealing
with uncomplicated pregnancies but are obliged to refer to a doctor in the
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THE PRIMARY HEALTHCARETEAM
event of complications. Midwives must be registered with the Nursing and
Midwifery Council.
Physician’s associate (PA) Rapidly growing healthcare role in the
UK. Support GPs in the diagnosis/ management of patients. PAs must have
undertaken a life sciences degree or other healthcare degree (e.g. nursing)
before entering 2y PA training. On qualication, PAs can take medical histories, perform examinations, analyse test results, and diagnose illnesses
under the direct supervision of a GP. In 209, PAs are not able to prescribe
although prescribing rights may soon be granted.
Community pharmacist Increasing role within practices— managing
repeat prescribing, monitoring prescribing practices, and advising on prescribing policy.
Social worker Help people to live more successfully within the local
community by helping them nd solutions to their problems. Social workers
tend to specialize in either adult or children’s services.
Other team members Might include paramedics, dieticians, occupa-
tional therapists, physiotherapists, psychologists, and/ or complementary
therapists.
Social prescribing Designed to support people with a wide range of
social, emotional, or practical needs. Enables healthcare professionals to
refer people to a range of local, non- clinical services, e.g. volunteering, arts
activities, group learning, gardening, befriending, cookery, and sports. Most
models of social prescribing involve a link worker or ‘navigator’ who works
with people to access local sources of support.
Intermediate care Community- based service working closely with the
PHCT. Provided by multidisciplinary teams. Provision and team composition varies across the UK but may include specialist doctors and/ or GPs,
nurses, physiotherapists and occupational therapists, home carers, and social workers. Usually provided in patients’ own homes but can also involve
community hospitals and/ or short- term nursing/ residential care placements. Common service features:
• Time- limited (usually <6wk)
• Targeted at people who would otherwise face prolonged hospital stays
or inappropriate admission to hospital
• Aims to maximize independence and enable people to remain living in
their own homes
Further information
British Association of Social Workers M www.basw.co.uk
Faculty of Physician Associates M www.fparcp.co.uk
Nursing and Midwifery Council (NMC) F 020 7637 78 (registra-
tions:F 020 7333 9333) M www.nmc- uk.org
Royal College of Midwives M www.rcm.org.uk
Royal College of Nursing M www.rcn.org.uk
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CHAPTER What is general practice?
Foundation doctors inprimarycare
Newly qualied doctors spend their rst working year (F) doing 3 hospital
placements before obtaining full registration. In the second year (F2), 42%
have a 4mo attachment to primary care.
Who employs foundation doctors? Foundation programmes are
hosted by hospital trusts. The trust recruits the doctors, arranges placements, employs them through their 2y programme, provides indemnity, appoints educational supervisors, and is responsible for assessment.
F2 placements ingeneralpractice
• Made by employing trusts; practices have no say about who they take
• Educational deaneries are responsible for appointing practices for F2
placements and interested practices should contact their local deanery
• Practices must be of adequate standard and have an approved
supervisor for their F2s; standard required is similar to that of training
practices (E p. 6)— practices are inspected by their deanery to check
they meet the criteria. GP F2 supervisors do not need to be GP trainers.
To attain approval, potential supervisors undergo a short training
course; they are paid at a rate related to the trainer rate
Expectations of F2 doctors
• Do 7 clinical sessions/ wk, session of supervised study, session of
project work, and attend a half- day group session at their host trust. No
OOH work is expected. Part- time working is allowed but training must
be undertaken on a ≥half- time basis
• Are entitled to study leave (up to wk) and annual leave
• Can sign prescriptions; practical procedures must be supervised
• Need an initial induction and are likely to need longer consultation times
than standard 0min slots
• Need to have a fully trained GP available whenever they are seeing
patients to provide advice and support and monitor their performance
Supervised learning events (SLE) Opportunities to receive feed-
back from senior colleagues. 3 types are commonly used:
• Direct observation of doctor/ patient encounters (minimum 3 in a
4mo placement). An experienced colleague watches the F2. Tools
available:Direct Observation of Procedural Skills (DOPS)— for practical
procedures; Mini Clinical Evaluation Exercise (Mini- CEX)— for clinical
consultations (must complete ≥2 in each 4mo period)
• Case- based discussion (CBD) Structured case review with a senior
clinician (minimum 2 in any 4mo placement)
• Developing the clinical teacher— or more/ y— designed to develop
the F2’s skill in teaching and/ or making a presentation
E- portfolio Compulsory record of training. Includes personal reections
and SLEs. The doctor must prove for the Annual Review of Competence
Progression (ARCP) that he/ she has performed all the core procedures
and attained all the competences required (Box .2) before progression
to specialist training. In addition, includes Team Assessment of Behaviour
(TAB), multi- source feedback, and clinical and educational supervisors’ and
Placement Supervision Group end- of- placement reports.
Further information
The Foundation Programme M www.foundationprogramme.nhs.uk
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FOUNDATION DOCTORS INPRIMARYCARE
Box .2 Summary ofthe 4 sections ofthe 206 foundation
level syllabus and 20 professionalcapabilities
Section :professional behaviour andtrust
. Acts professionally Professional behaviour; personal organization;
personal responsibility
2. Delivers patient- centred care and maintains trust Includes consent
3. Behaves in accordance with ethical and legal requirements Including
condentiality; statutory documentation; mental capacity; protection
of vulnerable groups
4. Keeps practice up to date through learning and teaching Self-
directed learning; teaching and assessment
5. Demonstrates engagement with career planning
Section 2:communication, team- working, andleadership
6. Communicates clearly in a variety of settings Communication with
patients/ relatives/ carers; communication in challenging circumstances;
complaints; patient records; interface with other healthcare
professionals
7. Works eectively as a team member Continuity of care; interaction
with colleagues
8. Demonstrates leadership skills
Section 3:clinicalcare
9. Recognizes, assesses, and initiates management of the acutely ill patient
0. Recognizes, assesses, and manages patients with long- term
conditions Includes:management of long- term conditions in the
acutely unwell patient; the frail patient; support for patients with
long- term conditions; nutrition
. Obtains history, performs clinical examination, formulates
dierential diagnosis and management plan Includes:history taking;
physical/ mental state examination; diagnosis; clinical management
and review; discharge planning/ summaries
2. Requests relevant investigations and acts upon results
Investigations; interpretation of investigations
3. Prescribes safely Correct and clinically eective prescribing;
discussion of medication with patients; guidance on prescribing;
review of prescriptions
4. Performs procedures safely Core procedures; other procedures
5. Is trained and manages cardiac and respiratory arrest Including do
not attempt CPR orders
6. Demonstrates understanding of the principles of health promotion
and illness prevention
7. Manages palliative and end- of- life care Including care after death
Section 4:safety andquality
8. Recognizes and works within limits of personal competence
9. Makes patient safety a priority in clinical practice Patient safety;
causes of impaired performance, error, or suboptimal patient
care; patient identication; use of medical devices and information
technology (IT); infection control
20. Contributes to quality improvement Quality improvement;
healthcare resource management; information management
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CHAPTER What is general practice?
Stress ingeneralpractice
Increasing stress is a feature of society. GPs score 2× the national average
on stress test scores. Similar gures are seen if anxiety scores are used and
in 4 GPs are classed as suering from depression if depression screening
tools are used. Burnout describes the syndrome of emotional exhaustion, depersonalization, low productivity, and feelings of low achievement.
Signicant numbers of GPs in all age groups are aected.
Causes of stress in general practice Insecurity about work (particu-
larly changes in NHS structure and complaints), isolation, poor relationships
with other doctors, disillusionment with the role of GPs, changing demands,
work– home interface, demands of the job (particularly time pressure,
problem patients, and emergencies during surgery hours), patients' expectations, and practice administration.
Roots of stress Many of the main stressors for GPs appear to be created
or perpetuated by doctors' own policies: overbooking patients, starting
surgeries late, accepting commitments too soon after surgeries are due to
nish, making insucient allowances for extra emergency patients, and allowing inappropriate telephone or other interruptions. Higher than average
pressure scores occur in doctors with fast consultation rates compared to
those with slower rates.
General characteristics of a stressed person at work Lack of
concentration, poor timekeeping, poor productivity, diculty in comprehending new procedures, lack of cooperation, irritability, aggression, withdrawal behaviour, resentment, i tendency to make mistakes, and resistance
to change.
Eects ofstress
• Eects on clinical work One study showed frustrated doctors are
more willing to take undesirable shortcuts in treating patients; another
that those doctors with negative feelings of tension, lack of time,
and frustration have poor clinical performance (measured by an i
prescription rate and lack of explanation to patients)
• Eects on practices Stress has eects on the practice too, resulting
in mistakes, arguments, or angry outbursts, poor relationships with
patients and sta, increased sta sickness and turnover, and accidents
• Eects at home Stressed GPs may develop problems in their
relationships with their partners and family at home, becoming
uncommunicative at home or work, and more withdrawn and isolated
Experience of stress does not necessarily result in damage. The extent of
stress necessary to d performance or satisfaction levels will depend on the
doctor’s personality, biographical factors, and coping methods but a concurrent illness or coexisting life event may have additive eects, and can i
vulnerability to stress or d ability to cope.
Alcohol Doctors commonly use alcohol as a coping method for stress.
The BMA estimates 7% of doctors are addicted to alcohol and/ or other
chemical substances, with half of those addicted to alcohol alone.
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STRESS INGENERALPRACTICE
Interventions andsolutions
• Improve your working conditions e.g. longer booking intervals for
patient consultations; develop a specialist clinical or academic interest
within or outside the practice; learn to decline extra commitments. GPs
with high stress levels do not necessarily have low morale but there is
a close correlation between levels of job satisfaction and morale— job
satisfaction seems to protect against stress
• Look at your own behaviour and attitudes Stop being a perfectionist;
resist the desire to control everything; don’t judge your mistakes too
harshly
• Look after your own health and tness Set aside time for rest and
relaxation; make time for regular meals and exercise
• Allow time for yourself and your family Do not allow work to invade
family time; consider changes in working arrangements to allow more
time for leisure and family
• Don’t be too proud to ask for help As well as formal channels for
seeking help, there are several informal doctor self- help organizations
and counselling services (see useful contacts)
Chronic stress E p. 976
Useful contacts
BMA Doctors Advisors Service and BMA Counselling Service. Provides
members and their families with help, counselling, and personal support.
Also produces a useful well- being webpage. F 0330 23 245 (24h)
M https:// www.bma.org.uk/ advice/ work- life- support/ your- wellbeing
British Doctors and Dentists Group Support group of recovering medical and dental drug and alcohol users. Students are also welcomed. Gives
condential help and advice through a local recovering doctor or dentist.
M www.bddg.org
Cameron Fund Provides a wide range of help and practical support to GPs
and their dependants. F 020 7388 0796 M www.cameronfund.org.uk
Doctors’ Support Network (DSN) Aims to raise awareness of mental
health concerns, encourage doctors to look after their mental health, and
to seek help early. M www.dsn.org.uk
GP Health Service For GPs/ GP trainees. Condential, self- referral NHS
service for mental health concerns (including stress/ depression) or addiction problems, especially where these might aect work. F 0300 0303 300
M http:// gphealth.nhs.uk
Royal Medical Benevolent Fund Provides specialist information and advice,
and necessary nancial assistance due to age, ill health, disability, or bereavement. F 020 8540 994 M www.rmbf.org
Sick Doctors Trust A condential intervention and advisory service for
alcohol- and drug- addicted doctors. F 0370 444 563 (24h) M www.sickdoctors- trust.co.uk
Further information
Lown M, etal. (205) Resilience:what is it, why do we need it, and can it
help us? BJGP 65:e708– 0.
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