Domhnall MacAuley: Floundering in the deep end – reflections on the RCGP conference

Domhnall MacauleyThe deep end. Floundering, treading water, trying to avoid drowning in the multiple morbidity, clinical complexity, and long, detailed, and difficult consultations in areas of deprivation. At the shallow end, GPs also work hard but can feel the bottom. Graham Watt  (Glasgow) described his work with GPs working in the most deprived areas of Glasgow at the RCGP conference “Diversity in Health.” He offered some stark figures to highlight the social inequalities. There isn’t just a 10 year difference in life expectancy but also at least a five year difference in healthy life expectancy. This means that men in the most deprived area are dead before those in the better off area develop significant illness. And, while multiple morbidity is more common in older people, most people with multiple morbidity are under 65. How might this affect general practice? Try swimming in the deep end.

Richard Horton who, as editor of the Lancet, champions global health, turned his attention to primary care in the UK. When asked how primary care could be an agent for change, he made three points: 

Every life has equal value – the Government doesn’t really seem to know this.

Tribalism has been the downfall of medicine- we need to work together, and in improving patient care, the leadership should come from general practice and public health.

And, we need to seek accountability.

Energetic, dynamic, and inspirational, he clearly values UK general practice – as we do.  And, two great European medical journals working together are a powerful lobby. When asked- what is the single greatest investment the RCGP could make in general practice research,   Prof Sir Lewis Ritchie (Aberdeen) pointed out the inequity in academic career opportunities so that in Scotland, for example, there are 17 times more academics from hospital medicine than general practice.  John Carnochan, Detective Chief Superintendent  at the Violence Reduction Unit in Scotland, didn’t feel research was the priority in his field. We do need research but the more urgent priority should be to implement what we already know. Use the knowledge we have. Perhaps a lesson for medicine too.

Other interesting sound bites: Sir Mike Rawlins agreed that NICE produces single disease guidelines but that no one has come up with a method to incorporate multiple morbidity. It was up to GPs to judge when guidelines should be applied and good medicine sometimes means ignoring them. 

The Secretary of State for Health, Andrew Lansley, who answered questions from a largely unsupportive audience pointed out that – we may have a universal health care system but it’s not uniformly good.  He told us that he had been listening for years to doctors who told him – give us the power. And, he seemed a little exasperated that his GP audience did not wish to rise to his challenge. As an uninvolved observer (the Health Bill in England will not affect our practice), I don’t think our questioners were any match for such an assured politician. Amateurs versus the professional, and I think he won the middle ground. 

Linn Getz (Norway) was one of the stars of the show, as usual, looking at patients beyond the human genome- but I may be biased as she usually integrates the music of Van Morrison into her presentation. A great weekend, and despite the tough times in primary care, the general buzz was positive and encouraging. So, when back at the coal face, its important to “remember there’ll be days like this.

Domhnall MacAuley is primary care editor, BMJ