Despite the Conservation party manifesto for the 2019 general election promising to deliver 6,000 additional full-time equivalent GPs, worryingly, the NHS lost 717 FTE GPs between March 2019 and March 2022, and the Health and Social Care Committee’s July 2022 report on workforce was scathing about the Government’s failure to act decisively on the chronic staff shortages across healthcare in the UK. This week, we speak to more colleagues from the RCGP conference: first, we talk to Pamela Curtis about the challenges of returning to general practice after a break; secondly, we speak to a group of GP trainees about their innovative platform, The Big GP Consultation, and hear their thoughts on shaping the future of general practice.

Our guests:

Pamela Curtis is a salaried GP working at NHS Bristol, North Somerset and South Gloucestershire ICB.

Veena Aggarwal, Devina Maru, Liam Loftus and Rachel Weaver are all GP trainees, and are part of the team for The Big GP Consultation.

Further reading:

House of Commons Health and Social Care Committee. Workforce: recruitment, training and retention in health and social care. 2022. https://committees.parliament.uk/publications/23246/documents/169640/default/

The Big GP Consultation. https://thebiggpconsultation.co.uk/

In this week’s episode, we share our experiences of attending the recent RCGP Annual Conference, and our thoughts on the topics that were covered in the talks at this year’s event. We talk to RCGP Chair, Martin Marshall, about continuity of care, which he states is one of the defining features of general practice. Evidence has shown that continuity of care is associated with better health outcomes for patients, but how can doctors convince politicians and policymakers of the benefits of it? We also speak to Emma Gladwinfield, a GP in Rossendale, about how connecting with schools, churches and community centres is helping to build relationships with patients and deliver care in her local community.

Our guests:

Martin Marshall is the Chair of the RCGP, a GP in Newham, East London, and Professor of Healthcare Improvement at UCL.

Emma Gladwinfield is a GP in Rossendale, East Lancashire.

Further reading:

‘Tackling the crisis in primary care’. doi:10.1136/bmj.o1485. https://www.bmj.com/content/377/bmj.o1485

As more and more pharmaceutical products come onto the market, there are so many potential drug interactions, and adverse reactions, to bear in mind during a consultation in primary care. In this week’s episode, we speak to Anders Holt, the author of a recent research paper looking at co-prescribing nitrates and sildenafil, which is surprisingly common, and adverse events associated with this. We also discuss the neuropsychiatric side effects of montelukast with Corine Ekhart, and talk about the challenges of striking the right balance between highlighting a rare but important side effect and causing the patient anxiety about taking the medication.

Our guests:

Anders Holt is a PhD candidate at Copenhagen University Hospital, Denmark.

Corine Ekhart is a pharmacist at the Netherlands Pharmacovigilance Centre Lareb in 's-Hertogenbosch, the Netherlands.

Further reading:

‘Adverse Events Associated With Coprescription of Phosphodiesterase Type 5 Inhibitors and Oral Organic Nitrates in Male Patients With Ischemic Heart Disease : A Case-Crossover Study’. doi:10.7326/M21-3445 https://www.acpjournals.org/doi/10.7326/M21-3445

‘Neuropsychiatric reactions with the use of montelukast’. doi:10.1136/bmj-2021-067554

https://www.bmj.com/content/376/bmj-2021-067554

A recent investigation, by The BMJ, showed a worrying increase in incidence of violence, directed to wards GPs, and reported to the police. In this episode of Deep Breath in, Tom and Jenny are joined by Gareth Iacobucci, assistant news editor for The BMJ who broke the story.

They'll hear from a GP affected, and get some advice on preventing violence, and deescalation, from two mental health experts, who deal with the most agitated patients.

Our guests:

Adam Janjua, a GP in Fleetwood, Lancashire.

Marcela Schilderman, a consultant psychiatrist at South London and the Maudsley NHS Foundation Trust

and Anita Bignell, a mental health nurse, at South London and the Maudsley NHS Foundation Trust

Reading list

Violent incidents at GP surgeries double in five years, BMJ investigation finds

https://www.bmj.com/content/377/bmj.o1333

Consultations about suspected cow’s milk protein allergies are quite common in primary care, but these allergies can be a challenge to diagnose, particularly as symptoms can manifest in many different ways, and testing can be complicated. We talk to Dr. Nicola Brathwaite about the diagnosis and management of cow’s milk protein allergies in infants, and our discussion includes how to navigate consultations with parents who may be distressed and fraught with anxiety over their baby’s symptoms, and how best to manage the reintroduction of milk back into the diet.

Our guest:

Nicola Brathwaite is a paediatric allergy consultant at King's College Hospital, London. She completed her specialist training in Paediatrics and Paediatric Allergy in Cape Town, South Africa.

Parosmia – a distorted sense of smell, and a delayed post-covid symptom – affects approximately 50% of people who experienced loss of smell during their initial covid infection, and it is currently attracting a lot of media attention. We hear from Emily Woodroofe, a third year medical student, about what it’s like to have parosmia, before we speak to Professor Claire Hopkins about what GPs need to know about it, and how they can best support their patients who are experiencing what can be a distressing symptom.

Our guests:

Emily Woodroofe is a third year medical student at Barts and The London School of Medicine and Dentistry.

Claire Hopkins is an ENT consultant, and professor of Rhinology at Guy’s and St. Thomas’ NHS foundation Trust.

Further reading:

‘Parosmia—a common consequence of covid-19’ https://www.bmj.com/content/377/bmj-2021-069860

With the focus on covid, and the pressure on hospitals, it may be easy to overlook what’s happening in general practice in the UK - but changes are afoot. Our new health secretary Sajid Javid doesn’t seem to like our long standing GP practice arrangement, NHS England has imposed new weekend working arrangements on the already stretched service, and the workforce pressures continue.

In this episode of Deep Breath In, our GP panel of Tom Nolan, Navjoyt Ladher, and Jenny Rasanathan are joined by Gareth Iacobucci, The BMJ’s assistant news editor, to give them the lowdown on what’s happening around primary care, who some of the key players are, and what his predictions for 2022.

We see patients all the time who ,more than any drug or cure, just want an explanation for their symptoms, to understand why they feel the way they do.

But giving an explanation isn't necessarily straightforward, we're unsure of the diagnosis, we might worry about how the explanation might be received, or a 10 minute appointment just isn't time to go into all the details.

In today's episode, we've enlisted the help of consultation skills expert, Roger Neighbour, and hear how important a great explanation is from The BMJ patient editor Amy Price.

Our guests:

Roger Neighbour is a retired GP and a former president of the Royal College of GPs. He has written the books on consultations skills, and teaches courses on how to put those skills into practice.

Amy Price is a patient, a researcher editor for The BMJ's patient and public partnership, and a senior research scientist at Stanford School of Medicine.

Diagnosis is a complex categorisation task driven by mental models that reside in long term memory. Through education and experience, clinicians form scripts that encapsulate their knowledge of specific conditions and develop diagnostic schemas that structure their approach to a specific health problem.

This cognitive process also intersects with systems, teamwork, and social factors that can enhance or reduce diagnostic accuracy.

In this podcast, we hear about five techniques that can help with the accuracy of those mental models, and mitigate against some of the external factors which may reduce diagnostic accuracy.

Our guests;

Hardeep Singh trained as a GP before moving to becoming a general internist and professor of patient safety research at Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine Houston.

Denise Connor is an associate professor of medicine at University of California San Francisco and a practicing internist at San Francisco Veterans Affairs Medical Center.

Gurpreet Dhaliwal is a general internist at the San Francisco Veterans Affairs Medical Center, and a clinician educator.

As Ramadan draws near, clinicians may be approached by their Muslim patients to discuss managing their health conditions during the month of fasting. How should someone with a chronic condition, such as diabetes or epilepsy, time their medications during this period? Can a person who’s pregnant or breastfeeding partake in fasting? What alternative options are available to someone whose health needs make participating fully in fasting too risky?

In this week’s episode, we discuss the many questions doctors and patients may have around this topic with Ammad Mahmood and Sahira Dar, authors of a recently published article in The BMJ on advising patients with existing conditions about fasting during Ramadan, and talk about the importance of individualised advice and shared decision making.

Our guests:

Ammad Mahmood is a neurological trainee, currently undertaking a PHD in stroke imaging at the University of Glasgow.

Sahira Dar is a GP, practising in Glasgow, with special interests in lifestyle medicine and mental health issues.

Further reading:

‘Advising patients with existing conditions about fasting during Ramadan’ by Ammad Mahmood, Sahira Dar et al. https://www.bmj.com/content/376/bmj-2020-063613