The launch of the RCGP Rural Forum

Glasgow RCGP conference 2009

Dr Malcolm Ward

RCGP Rural Practice Standing Group

The Rural Practice Group was founded in 1993 to raise the profile of rural medicine in the United Kingdom through education, research and the dissemination of good practice in rural health care.

Key issues for rural patients

• Access to services• Threats to local services posed by centralisation policies

(Darzi report) • Poor public transport • Community hospitals• Minor injuries and pre-hospital care as essential (rather

than optional) practice commitments.• Rural deprivation /mental health• Agricultural workers Health and Safety• Pharmaceutical services - GP dispensing

Additional concerns of rural doctors• Last of the true generalists?: Maintaining,

updating skills

• Political initiatives that favour large practices (money follows the patients)

• Privatisation by stealth

• NICE e.g. Minor surgery

• Single handed GPs: OOH, recruitment, political attitudes

• Revalidation

• New registration rules?

Rural Group survey April 2008• 63% of respondents were from Scotland (total 144)• 83% were GP principals• 32.6% were not RCGP members• 57% had >4hrs of travel time to attend geographical faculty

meetings• 77% said they had no college involvement• 72.6% were dispensing• 52.4% 10-50 miles to nearest DGH, 27.4% > 75miles• 72% thought the College has little or no understanding of rural

issues• The majority were not happy with the current geographical faculty

arrangements and preferred the formation of a UK rural faculty as opposed to devolved faculties or a separate rural college.

• 63% of non members would become RCGP members if there was a rural faculty.

UK Council Feb 2009:The vote

• The first vote concerned the establishment of a non-geographical rural faculty. The result of the vote was:

• For: 17 • Against 33 • Abstentions 6 • The proposal to establish a ‘Faculty’ therefore fell. • The second question was the approval of the concept of

establishing a grouping representing rural and remote GPs within the College, as set out in the paper, but without the term ‘Faculty’. This gained overwhelming support from Council, with the result:

• For 44 • Against 0 • Abstentions 5

Forum = Faculty?

Developing the Rural Forum

What can we learn from Australia?

• It has not been possible to include Richard Hays’ video in this slide cast

Key messages from Richard Hays

1. Key purpose to improve rural health rather than focus on just professional issues

2. Avoid ACRiMony: work within the College

3. Set out Forum objectives: training, education, support, advocacy for members

4. Broad coalition/inclusivity

5. Identify rural stakeholders and keep engaged with them

Mission statement?

Learning from key point 1 from Richard Hayes:

To improve the health of the rural population throughout the UK ?

Overall aims of the Rural forum• To represent rural and remote general practitioners within the RCGP with

the potential to promote rural issues within and outwith the College faculties and be the rural face of the College

• To encourage engagement with the College of those fellows/members working in rural practice.

• To facilitate communication between and networking of rural doctors across the UK.

• To support the professional development of rural general practitioners, with particular reference to the required knowledge, skills and attitudes of a general practitioner to care for patients in a rural setting.

• To promote rural practice and support associates in training with particular reference to the required knowledge, skills and attitudes.

• To promote rural practice as a career path for associates in training and through the College strive to ensure availability of appropriate training.

• To promote remote and rural issues at appropriate level, engaging with the profession, managers and informing political debate.

• Democratic infrastructure

 

Rural Forum Steering Group• Chris Clark (Cornwall)

• Aidan Egleston (DDA)

• John Elder (Lins)

• David Hogg (AiT)

• Paul Kettle (Orkney)

• Robert Lambourn (Northumberland)

• Jane Randall-Smith (IRH)

• Michael Smyth (N.I.)

• Susan Taylor (RPAS)

• Russell Walshaw(GPC)

• John Wyn-Jones (IRH)

• Malcolm Ward (chair)

Once we achieve a substantial membership we can hold elections

for the Steering Group

It will be your Forum and the membership will determine

how the Forum evolves

Membership benefits• Belonging to a Forum which specifically represents the interests of

rural practitioners in the care of their patients at all levels.

• Once a Forum membership/constituency is established a democratic representative structure can be created.

• A virtual system of communication via E-communication and web based facilities.

• Opportunity to comment on, and influence College policy.

• Opportunity to influence College interaction with other relevant

agencies where their policies and initiatives may impact upon rural healthcare. E.g. SAS consultation, Scottish OOH consultation

• E-learning: sign posting, rural modules, ?CD-ROM option

Examples of what the Forum can do

• Rural proofing Revalidation

• Explore, develop rural health e-learning options

• Practice support, sign posting re topical issues e.g.PCF development.

• Promote and sign post rural health research

• Develop a Rural E-network that will enable YOU to inform us of your concerns and needs.

Primary Care Federations

“GPs are good at adapting to change and seizing opportunities for improvement. We can achieve more through GP practices working together than by individual practices working in isolation.”

RCGP chairman Professor Steve Field

Examples of areas where improvements to patient services and to GP’s lives might be gained via PCFs are:

• Out of hours services where there are still problems• Holiday and sickness cover• Gaining GP quest cover enabling combined practice

education/training events• Improving minor injury services• Improving and extending minor surgery provision• Improving access to investigations e.g. mobile MRI • Improving transport for test samples to improve result

turnover.• Greater negotiating powers for improving premises to

provide improved range of services.

• Desk top analysers at a designated site• Improving access to Physiotherapy, chiropody services• Providing counselling services or extending existing

service • Drug, alcohol support services• Outreach specialist consultant clinics, GP specialist

clinics, nurse specialist clinics• Potential for improvements in practice management with

shared expertise• Increased purchasing power for practice requisites• Increased potential in Practice Based Commissioning

(where national governing bodies advocate PCB)

LCG Configuration

Revalidation: Evidence areas

1. Statement of basic professional roles and other basic details.

2. Statement of exceptional circumstances e.g. career breaks, illness, maternity leave etc.

3. Evidence of active and effective participation in annual appraisals.

4. A personal development plan (PDP) from each appraisal.5. A review of the PDP from each appraisal.6. Learning credits in each year (50) of the revalidation

period and revalidation (total 250 over 5 yrs).7. Multi source feedback (MSF) from colleagues(x 2/5yrs_

normally in year 1 or 2 and in yr 4 or 5).

Evidence areas continued:

8.Feedback from patients ( 2 patient surveys/5 yrs)9. Description of any cause for concern or formal

complaint.10.Significant event audits (minimum of 5 demonstrating

reflection and change and discussion at appraisal).11. Clinical Audits of the care delivered by the GP in at

least two significant clinical areas of their practice, with standards, re-audit and evidence of both appropriate improvement, compliance with best practice guidelines and discussion in appraisal.

12. Statement of probity and health, and use of health care, including registration with a GP in another practice; evidence of appropriate insurance or indemnity cover

13. Additional evidence for areas of extended practice.

How will CPD learning credits be awarded?

Range of credit scoring activities• Background reading eg BMJ, BJGP• Targeted reading, eg case prompted internet

searches/reading, or to plug recognised knowledge gaps • Attendance of conferences, educational meetings• Training courses: new skills, improving skills eg to

become GP trainer• On line learning: RCGP/BMA e-learning modules• Clinical audit• Learning from significant events/improved clinical

practice• Research• Practice/service innovations that improve patient careetc,

Demonstration of Impact to attract Additional Credits (x2)

• Activities which attract additional credits demonstrate the introduction of newly acquired knowledge or skills; they may be evidenced by an individual case report or series of reports; a reflective commentary demonstrating a change in practise e.g. as a result of an e-learning module; a significant event leading to risk avoidance; a practice protocol or a change at the individual level could also be highlighted.

• This activity will benefit the individual, the patients or the system more than simply knowing about a development and should be rewarded by additional credits. This phase may happen long after the learning experience.

Example of enhanced crediting• An individual attends a meeting (1 hour) on heart failure, acquires

the knowledge that certain beta-blockers are beneficial in this condition and then records this within their appraisal documentation.

Credits claimed 1 - this demonstrates the acquisition of knowledge and as yet there is no demonstration of personal, practice or patient benefit.

• Another individual attends the same meeting. The acquisition of knowledge is recorded however in their appraisal folder, an audit is planned after consideration of current practice (1 hour), they demonstrate audit of their patients with heart failure, changes are made appropriately following discussion with colleagues (1 hour) and a 2nd audit cycle demonstrates an improvement in care.

Credits claimed 1 (initial meeting (1 hour)) + 2 (planning (1 hour) and discussion associated with audit (1 hour)) X 2 (Impact) = 6

 

Specific expressed concerns for small or remote practices:

1. Multi source feedback (MSF)

2. Clinical audits

3. Significant Event Auditing (SEA)

4. Learning Credits.

MSF• Recruiting sufficient numbers of clinical and non-clinical

colleagues to respond to an MSF. [This is complicated by the employment of spouses]

• The limited pool of colleagues means that comments would be more easily attributed.

• If not a full sample of colleagues, would that reduce the validity and/or increase the risks of breaches of confidentiality?

• Additionally, the participants reported concerns common to all doctors: would an MSF be used to “settle scores”? How will feedback be given?

RCGP to consider solutions, & learn from other countries

Clinical audits

• Problem of getting sufficient numbers to be of statistical significance where small list size.

Proposed solution: to give guidance as for sessional doctors to allow appropriate flexibility in audit topic choice to minimise this effect.

SEA

Significant event audits are team-centric. Although single-handed doctors do have teams, the absence of a peer on whom to reflect clinical views might be a problem for GPs in small practices. The group considered that small practices either manage to undertake SEAs effectively in-practice or can join a “quality assurance group” or “educational federations” to share SEAs.

Learning Credits

• It was felt that there would be potentially greater problems for remote doctors in achieving their learning credits. Access to Protected Learning Time was rare and access to appraisers who understand rural practice (with its specialist skills) was limited.

•  Difficulties in attending distant courses, educational meetings.

Solution? On-line learning, RCGP/BMA e-modules Create appropriate rural practice e-

modules

College CPD credit score benchmarking tool

www.rcgp.org.uk/practising_as_a_gp/professional_development/cpd_credits_scheme/benchmarking_tool.aspx

The rural blog

Rural blog: Use or lose

• Independent of RCGP RF but associated

• Rural GP resource and central portal to other resources

• Looking for contributors, news copy

• Need feedback, innovative ideas

• 6 month pilot

Membership

The Rural Forum is open to all RCGP Members, Fellows, and Associates in Training who declare an interest in rural general practice and signal their wish to join.

Sign up today!• The scale of the membership at the end of

the 2 year pilot could be the deciding factor when the College evaluates the RF achievements and determines whether it has a future within the College.

• Please fill in an application form NOW and give to Saqib or Frances – there is nothing to lose!

Ask your partners to sign up on line

• Joining the Forum is a simple process that you can do now online.

• If you already have an RCGP online services login • Go to the online services members area [

https://integra.rcgp.org.uk/membersarea/login/login.asp?type=EXTRANET] and login.

• If you do not yet have a members area password you can request one by emailing helpdesk@rcgp.org.uk or telephone us on 020 7344 3182.

Worksheet

Application form

and the Rural Forum needs you!

You need the Rural Forum