Contribution of Senior Academic GPs to the NHS: evidence submitted by SAPC to the DDRB in 2010

This response is on behalf of senior academic GPs within the Society for Academic Primary Care. The response represents the views of senior academic GPs in the UK, including heads of departments of general practice and primary care in UK medical schools.

Summary

This document sets out some of the benefits to the NHS of senior academic GPs (SAGPs) having access to the clinical excellence award scheme. It also highlights the potential risks to recruitment and retention of talented clinical academics if these awards were substantially scaled-back, or withdrawn, with consequent effects on clinical service re-configuration and policy delivery.

There are around 200 senior academic GPs in the UK. Those that hold clinical excellence awards provide substantial benefits to the NHS through:

 Research to provide the evidence-base for high quality health care;

 Contributing to embedding a culture of research, evaluation and reflective practice within the NHS;

 NHS service development;

 Management and leadership;

 Clinical education including providing excellent learning for future generalist clinicians who are able to deliver high quality, cost effective care that people need close to where they live;

 The provision of high quality clinical care.

Without access to clinical excellence awards, the vast majority of full-time senior academic GPs would earn substantially less that the average full-time GP partner. If awards were substantially scaled-back, or withdrawn, this would seriously affect retention of the most talented and experienced senior academic GPs, with subsequent loss to the health service in terms of leadership, service development, clinical education and research excellence. Recruitment to academic general practice would also be seriously damaged because of the lack of future financial reward compared with a career solely in clinical practice. In addition, activities that lead to academic career progression would probably be prioritised over wider contributions to the NHS.

For these reasons we advocate the continuation of the clinical excellence award scheme, which we believe justly reward the value of the work that clinical academic GPs undertake for the NHS.

Of necessity, this response paper can summarise only a range of evidence relating to the activity and contribution of SAGPs. We have been selective in highlighting areas which we 2

believe will be of particular interest to DDRB in undertaking their review of the national CEA scheme.

Overview

The press release from the Department of Health, issued following the statement by the Secretary of State for Health in August 2010, mentions only consultants in relation to clinical excellence awards1. It is, however, reassuring that the evidence provided by ACCEA to DDRB23 does note the eligibility and full participation of senior academic GPs, holding honorary consultant contracts, in the awards process. We assume that the omission in referencing SAGP eligibility arises from the small numbers involved relative to the wider consultant community.

1 http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_118799

2 Tables 8&9 in http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_120212.pdf

3 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_107478.pdf

SAGPs represent a small number of academics working more than half their working week in Universities at senior lecturer level and above (professor, reader, associate professor, senior lecturer). SAGPs total fewer than 200 individuals across the UK (compared with a pool of over 36,000 eligible consultants in England alone). SAGPs have been eligible for CEAs since 2004 (in all the countries of the UK except Northern Ireland) addressing a long-standing inequity relative to other clinical academics and GP partners.

SAGPs and the NHS

Like their consultant clinical academic colleagues, Senior Academic GPs (SAGPs) make significant contributions to the NHS at national level; this contribution is over and above their contracted roles in universities.

Examples of such contributions from national CEA award holders include:

1) Research to provide the evidence-base for high quality NHS health care

a. Research that has influenced clinical care:

i. Professor Butler: has led a 14 county study that demonstrated a four-fold, unhelpful variation in antibiotic prescription for acute cough/lower respiratory tract infection. His trial on point of care testing and enhanced communication skills has shown how such unnecessary antibiotics can be safely reduced.

ii. Professor Delaney: has undertaken a major body of work providing evidence for the management of dyspepsia and gastro-oesophageal reflux disease.

iii. Professor Fitzmaurice: has published landmark papers around screening and treatment of atrial fibrillation, and self-management of oral anticoagulation.

iv. Professor Hannaford: has led the RCGP oral contraceptive study which has provided important evidence on the safety of oral contraceptives.

v. Professor Hobbs: has undertaken many studies in the field of cardiovascular medicine, including the use of Natriuretic peptides in the diagnosis and management of heart failure.

vi. Professor Khunti: has undertaken RCTs of structured self-management educational programmes for people with diabetes (DESMOND study) which have now been rolled out to over 50% of PCTs in England. He has also undertaken major studies on screening and prevention of diabetes. The work has directly influenced Department of Health’s NHS Health Checks Programme.

vii. Professor Little: has undertaken major studies that have informed the management of infection in primary care, including the use of delayed prescriptions.

viii. Professor Sullivan: has demonstrated convincingly the benefits of high-dose oral steroids in the management of Bell’s Palsy.

ix. Professor Smeeth: has undertaken groundbreaking work establishing a role for infection in triggering vascular events; and has led the MRC funded case-control study of MMR vaccination and autism, widely credited with restoring public faith in the vaccine.

x. Professor Underwood: has informed NICE guidance on management of low back pain as a result of the finding of the BEAM trial.

b. Research that has evaluated quality of care:

i. Professors Roland and Campbell: have evaluated the national GP patient survey and General Practice assessment questionnaire – both instruments being incorporated in the national GP contract, the former being used to directly inform the allocation of £70m NHS resource.

ii. Professor Salisbury: has evaluated General Practitioners with Special Interest services; NHS walk-in centres and access to primary care.

c. Development of clinical risk assessment utilities:

i. Professor Hippisley-Cox: has developed and validated the QRISK2 for cardiovascular risk which is now used widely across the NHS. She has also developed QFracture for risk of osteoporotic fracture and QDscore for risk of developing Type 2 diabetes. These tools allow a targeted approach to prevention by identifying those at highest risk of major outcomes most likely to benefit from interventions to reduce risk.

ii. Professor Feder: has developed the FRAT for falls risk in older people, and HARK for domestic violence.

iii. Professor Khunti: developed the first multi-ethnic diabetes risk score which is now being promoted to PCTs and by Diabetes UK to the public; 45,000 people visited the risk score within 10 weeks of its launch on the Diabetes UK website.

d. Leadership of major NIHR research programme grants (SAGPs have been extremely successful in obtaining these highly prestigious NHS research awards):

i. Professor Croft - Clinical osteoarthritis and joint pain in older people: optimal management in primary care.

ii. Professor Dowrick – increasing equity of access to high quality mental health services in primary care.

iii. Professor Feder - Improving the health care response to domestic violence.

iv. Dr Griffin - Reducing the burden of type 2 diabetes: translating epidemiology and behavioural science into preventive action.

v. Dr Hay - Improving the use of antibiotics for children with acute respiratory infections in primary care.

vi. Professor Iliffe - Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life.

vii. Professor D Kendrick – Keeping children safe at home: a multicentre collaborative research programme to reduce childhood injuries.

viii. Professor Khunti – Prevention of diabetes in high risk people.

ix. Professor Little – Primary care Infection Management for Everyday practice (PRIME).

x. Professor D Mant - Development and implementation of new diagnostic processes and technologies in primary care.

xi. Professor J Mant: Stroke Prevention Programme

xii. Professor Salisbury - on the expanding role of NHS Direct in supporting people with long term conditions.

xiii. Professors Roland and Campbell – improving patient experience in primary care.

xiv. Professor Tylee - developing and testing stepped care for patients with depression and physical illness in primary care.

xv. Professor Underwood - Improving outcomes from the treatment of back pain.

e. Recognition of NHS research contributions through NIHR Senior investigator awards: Professors Baker, Croft, Dowrick, Eccles, Greenhalgh, Hobbs, Kinmonth, Little, Jonathan Mant, Roland.

f. Direct involvement of SAGPs in leading, or undertaking programmes of work, in all nine of the NIHR CLARHCs (Collaborations for Leadership in Applied Health Care) focusing on the translation of evidence in to practice to improve quality of care in the NHS. Examples of major leadership contributions include Professors Baker, Campbell, Kai and Khunti.

2) Contributions towards NHS quality and service development

a. The Manchester group’s work on the quality and outcomes framework (QOF) (Professor Lester, and formerly Professor Roland) has considerably enhanced the evidence-base and rigour of this major initiative. Several SAGPs have input to the QOF advisory committee (Vice Chair is Professor Smeeth; members include Professors T Kendrick and L Ritchie).

b. Professor Eccles is Chair of the Implementation Strategy Group for the National Institute of Clinical Excellence (NICE). Professors Esmail and Baker played major roles in the Shipman Inquiry and associated investigations, influencing policy on death certification, the coronial system, controlled drug prescribing regulations, and appraisal and revalidation of doctors.

c. Professor Pringle has led improvement in the quality of data recording in general practice through the establishment and development of Primary Care Information Services (Primis+). He is also clinical lead for revalidation for the RCGP. He developed Significant Event Auditing which is now used for quality assurance in primary care, is part of the GP contract, and will be part of the supporting information for GP revalidation.

d. Chairing and participating in NICE guideline development:

i. Antibiotic prescribing: Professor Little (Chair).

ii. Chest pain: Professor Smeeth.

iii. Common mental disorders: Professor T Kendrick (Chair).

iv. Chronic Fatigue Syndrome: Professor Baker (Chair), who also was instrumental in establishing NICE’s primary care collaborating centre, producing the guidelines on obesity, epilepsy and cancer referral.

v. CVD risk assessment and lipid guidance: Dr Robson.

vi. Depression: Professors Tylee and Dowrick. 　

vii. Diabetes: Professor Farmer.

viii. Dyspepsia/GORD: Professor Delaney.

ix. Prevention of Diabetes: Professor Khunti (Chair).

x. Strategies to prevent unintentional injuries in the under 15s: Professor D Kendrick

xi. Stroke: Professor McManus.

e. Providing education and training for health care professionals:

i. Establishment of the National Centre for Anticoagulation Training (NCAT) – Professor Fitzmaurice

ii. Development and successful implementation of service level training and e-resources for new NHS antenatal and newborn screening programmes for sickle cell and thalassaemia in all maternity Trusts in England; and the first national standardised training for specialist counselling in this field (Professor Kai).

f. Development and delivery of real time surveillance systems: Professor Hippisley-Cox has established QSurveillance which is the world’s largest near time surveillance system which is used extensively by the HPA and Department of Health to alert to and monitor infectious disease (including the H1N1 pandemic); it is part of the UK Health Wave Plan and part of the national emergency response to chemical and natural disasters.

3) Management and leadership that benefits the NHS

a. Taking on senior roles in UK medical schools:

i. Dean, Durham Medical School - Professor Hungin.

ii. Dean, Hull-York Medical School - Professor Kendrick.

iii. Dean, Warwick Medical School - Professor Yvonne Carter.

iv. Dean of Learning and Teaching, School of Medicine, University of Glasgow – Professor Morrison.

v. Dean of Research, School of Medicine, Cardiff University - Professor Butler.

vi. Head of School, Keele University - Professor Wass.

b. Holding major national posts within the Royal College of General Practitioners:

i. Professor Field, current Chair.

ii. Professor Pringle, past Chair.

iii. Professor Howe, current Honorary Secretary.

c. Directing, chairing or membership of NIHR, or similar, bodies:

i. Professor Wallace, Director of Primary Care Research Network, England.

ii. Professor Hobbs, Director, English National School for Primary Care Research.

iii. Professor Butler, Foundation Director, Wales School of Primary Care Research and Associate Director, National Institute for Social Care and Health Research Clinical Research Centre, Wales.

iv. Professor Sullivan, Director, Scottish School for Primary Care.

v. Professor Little, main panel and sub-panel chair of the NIHR Programme Board.

vi. Professor Majeed, Primary Care Lead, National Children’s Medicines Research Network.

vii. Professor Farmer, Deputy Chair, HTA commissioning.

d. Roles in other national bodies that benefit the NHS

i. Professor Butler: Chair of Wales Antibiotic Resistance Group

ii. Professor Marshall, Clinical Director and Director of Research and Development at the Health Foundation, and former Deputy CMO for England.

iii. Professor Nazareth, Director MRC General Practice Research Framework.

iv. Professor Pringle, past member of GMC Council.

v. Professor Ritchie, Chair: Scottish Government - Scottish Medical & Scientific Advisory Committee (SMASAC)

vi. Professor Weller, Primary Care Lead (2003-9) National Cancer Research Institute.

vii. Many SAGPs have a direct current role in hosting, supporting, and overseeing NIHR research network related activity; the English Primary Care Research Network has national coverage due to the engagement, foresight and planning delivered by SAGPs in 2004, and ongoing regional leadership by many SAGPs.

viii. Directorships of CLRNs.

4) Clinical education for the NHS: SAGPs have developed, delivered and managed teaching programmes and provided their skills as external assessors. They have written textbooks and informed the development of national teaching curricula. Examples include:

a. Professor Howe: Course Director for the MB/BS at UEA in 2005. She led the course through the final two years of its first cohort of students to successful GMC validation & Queen's award in June 2007.

b. Professor Jones: Editor, Oxford Textbook of Primary Medical Care.

c. Dr Silverman has promoted communication skills teaching in medical schools and the NHS thorough his internationally respected Calgary-Cambridge training programme; he founded the UK Council for Communication Skills Teaching in Undergraduate Medical Education which has become a significant force in collaboration between medical schools in education, research and policy.

d. Professor Spencer, Professor of Primary Care and Clinical Education, and Sub Dean for Primary and Community Care, Newcastle University.

5) Provision of high-quality clinical care

a. SAGPs provide very high-quality clinical care as evidenced by consistently good feedback from patient satisfaction surveys.

b. SAGPs have been instrumental in developing high-quality practices. They have, for example, developed their own inner city practices as local hubs for service innovation, commissioning and multidisciplinary learning or as Healthy Living Centres (Professors Illiffe, Kai and Mathers).

c. Dr Parimjit Gill led the development of high quality care in a single-handed, deprived and diverse practice in Birmingham, starting from a low baseline and recently achieved a 98% QoF score. The practice is now active in both research and training of health professionals. Further, this dynamic practice attracts visitors from within and outside the UK.

d. Professor Watt is coordinator of the Deep End Project, working with the 100 most deprived Scottish general practices.

It should be noted that many of the management and leadership roles taken on by senior academic GPs, that bring such benefits to the NHS, are done in addition to full-time academic and clinical commitments; most SAGPs work well over their contracted hours. 7

SAGPs and academic consultant colleagues

SAGPs undertake comparable roles to their colleague consultant clinical academics within medical schools. This was the basis on which they were given access to the clinical excellence award scheme. Arrangements pertaining prior to 2004 meant that SAGPs were financially differentially disadvantaged compared with these colleagues, whilst undertaking similar roles. Being academics employed by universities meant that they were not rewarded through the new GP contract implemented in 2004. That situation embedded and reinforced the particular difficulties experienced by UK academic general practice in recruiting to this clinical academic specialty, only reversed in recent years where, counter to the prevailing norm, academic general practice was one of only two clinical academic specialties observed by the Medical Schools Council to have increased in capacity4. It is likely that the availability of CEAs to senior academic GPs contributed to that advantageous change in recruitment.

4 Fig 8 page 15 in http://www.medschools.ac.uk/AboutUs/Projects/Documents/Clinical%20Academ...

5 Page 21 in http://www.medschools.ac.uk/AboutUs/Projects/Documents/Clinical%20Academ...

Notwithstanding the observation of the previous paragraph, that same report5 noted the problems of UK academic general practice whereby ‘comparison of headcount and FTE numbers reveals two unique specialties, General Practice and Medical Education [emphasis added], with fewer than 40% of clinical academics on a full time contract with the university compared with an average of 90% across the other specialties.’ Thus, whilst there is some evidence of recent benefits accruing in recruitment to academic general practice in the UK following the recent eligibility of SAGPs for CEAs, the present staffing situation may legitimately be regarded as somewhat precarious; any differential change in the status of SAGPs with respect to eligibility for CEAs has the potential to significantly destabilise an already precarious situation.

We note that SAGP colleagues in Northern Ireland do not have eligibility for CEAs. This is an anomaly and we suggest that the DDRB advocate that the small number of SAGPs involved is given eligibility to clinical excellence awards in the future.

Contribution to CEA Awards process

SAGPs have participated actively in the CEA awards process, with several holding membership of regional awards committees:

Cheshire and Mersey Professor Mark Gabbay

East of England Professor Ann-Louise Kinmonth

East Midlands Professor Joe Kai

London North-East Professor Liam Smeeth

London South Professor Sean Hilton (vice-chair)

London South Professor Andre Tylee

South-West Professor John Campbell

Also, through the national academic representative body (Society for Academic Primary Care) and RCGP, SAGPs have contributed constructively to national level discussions and negotiations (Professor Avery).

Recruitment and retention of SAGPs

Recognition of SAGPs through the clinical excellence award scheme is essential to the continuing recruitment and retention of this small group of clinical academics who drive innovation and improve the quality of clinical care in general practice. The national system, competed for by SAGPs on identical terms with their Consultant colleagues, represents the most efficient way by which these senior clinical academics can have their efforts on behalf of the NHS recognised.

Eligibility for CEAs has represented a vitally important step in the development of general practice as a clinical and academic discipline within the NHS and UK universities. Without a national CEA, a clinical professor of general practice with 20 years of experience at senior lecturer level or above, working 11 programmed activities a week, would be substantially disadvantaged financially when compared with a full-time partner in a general practice. Furthermore, without eligibility for CEAs there is a serious risk that SAGPs would consider leaving academic work and going into full-time general practice or moving abroad. Indeed, SAGPs are contacted regularly to apply for attractive professorial positions in countries outside of the UK. It is clear that CEAs have helped retention of the best SAGPs in the UK, and without such eligibility, many would be attracted abroad.

For even the most talented GPs entering an academic career, it is likely to be 15-20 years before they achieve a national Clinical Excellence Award. In the early years, academic GPs often have to spend 5 or more years achieving a PhD (or gaining equivalent educational experience) before they become eligible for a senior lecturer position. During this time, and for many years after, most earn considerably less than a GP who has gone into full-time practice. Without access to the Clinical Excellence Award scheme, a doctor contemplating a career in academic general practice, would face the prospect of earning considerably less than a full-time GP during the whole of their professional lifetime. This, we believe, would have a devastating effect on recruitment to academic general practice. 9

Conclusion

The clinical excellence award scheme represents a very important national initiative for recognising and rewarding Consultants and Senior Academic GPs for contributions made to the NHS. The continuation of the scheme will provide ongoing incentives and rewards for the major role played by senior academic GPs in informing and developing high quality care for patients through education, research and service development, relevant to the needs of the NHS. This has never been more important than at the current time when general practice is set to play an increasing role in commissioning.

19 November 2010

Tony Avery

Professor of Primary Health Care

University of Nottingham

John Campbell

Professor of General Practice and Primary Care

Peninsula Medical School, Exeter

Chris Butler

Dean of Research

Cardiff University

Margaret Cupples

Reader in General Practice

Queen’s University Belfast

Helen Lester

Chair SAPC

Professor of Primary Care

University of Manchester

Frank Sullivan

Director of Scottish School for Primary Care

Chair, SAPC Heads of Departments Group

University of Dundee

Graham Watt

Professor of General Practice

University of Glasgow