How wonderful that at last after more than 40 years a Senior Colleague has recognised that as a profession we lack knowledge, skill and experience in the process of "education". On-line, solitary reading and multiple choice questions may lead to satisfying the requirements of revalidation but as Clare reminds us "it is conversation within our peer groups that leads us to the exploration of the significant uncertainties that is at the heart of everything we do as doctors".

There is a book on my shelf at home titled "Over Schooled but Under Educated". It makes it clear that much of what passes for "education" in the UK is in fact just "schooling" and not "education" at all -- i.e. it does not lead young minds to begin to love learning nor does it help students to start out on a journey of discovery to find the intellectual passions that will lead to a rich and happy life. Similarly what now passes for CPD sessions in General Practice is too often a lonely soul destroying misuse of time, money and energy. This approach to CPD and adult education in medicine and other professions seems to me to be the outcome of our collective failure to value the work of colleagues who really do understand and value education in its truest sense. Our modern world and our medical profession urgently needs to listen to real educationalists like Lewis Mumford.

About our modern world Lewis Mumford writes: "The most deadly criticism one could make of modern civilization is that apart from its man-made crises and catastrophes, it is not humanly interesting...In the end, such a civilization can produce only a mass man: incapable of choice, incapable of spontaneous, self-directed activities: at best patient, docile, disciplined to monotonous work to an almost pathetic degree, but increasingly irresponsible as his choices become fewer and fewer".

Being a GP is all about choices - choices about where to work and how to practise but just as importantly it is about helping patients and carers to see and understand the choices that they can make when faced with ill health, disease, difficult circumstances and maybe life limiting conditions. To be a doctor able to help patients and carers to make decisions and choices means that as a profession we must be the people that can facilitate the education and learning of our patients. Clearly if we are not ourselves people that love learning and people that fully understand that learning requires the right environment and motivation then we will not be able to help our patients to learn and make good choices themselves when faced with various treatment options.

Back in the late 1970s Dr John Macdonald at The Dept. of Education,University of Bristol, stated in Occasional Paper No 64, RCGP, that "alongside every GP Practice" there needs to be "a huge and sustained educational programme if patients are to be fully involved in their treatment and care". Maybe, just maybe, the contribution today from Clare Gerada might just possibly lead to a proper consideration of this neglected but very important aspect of our work as GPs.

The NHS could offer more fulfilling lifelong careers by taking more of an interest in the daily lives of those who work for it. Understanding a job plan is insufficient to understand the stresses and strains of work on the front line. Gone are the days of endless hours on-call, but the daily challenges of increasingly early starts to catch up with the accumulation of work, trying to avoid living off the hospital vending machines, fighting for a parking space or even receiving a ticket for parking at your place of work - as well as constantly rotating to new trusts with ever varying computer systems, protocols and passwords - distract and discourage and can slowly grind a workforce down.

To keep the plates of patient care spinning throughout the day is a never-ending and often amazing stage show played to an audience of none: everyone is just too busy to notice. The performance relies on ad-libs, leeway and workarounds. Understanding that ad-libs are necessary, understanding the need for leeway and understanding the nature of the workarounds is vital to an understanding of how the system and the people in that system really work. All of these things however are usually unseen, ignored or misinterpreted as being due to lack of professionalism, lack of commitment, lack of cooperation, lack of motivation, lack of intelligence or just plain laziness.

Currently the gulf is a very wide one - and unlikely to be addressable over a cup of tea - or by one.

We would like to clarify that Cancer Research UK does not incentivise GPs with payments for improving screening uptake as could be inferred from the article, but that these payments are offered by CCGs. We believe that increasing uptake should not come at the expense of informed choice but through removing barriers to screening, so that individuals who want to attend are able to.

Cancer Research UK agrees that doctors should not be persuading patients to go for breast screening. But for all screening programmes, GPs should raise awareness of screening, give patients the information they need to make an informed decision and be available to answer any questions or concerns patients might have.

The first of April is the day the Quality and Outcomes Framework (QOF) year starts. It is supposed to be the day each practice in England is ready to monitor the targets and objectives based on guidance from NICE and agreement with the BMA following yearly negotiations. And indeed each year several indicators are changed, and for 2019/20 there is no exception. Initial guidance was released at the end of January [1]. Unfortunately the QOF seem to be the usual bad joke as:

-There is inadequate support: NHS fails through their website ‘NHS employers’ [2] to show the current full set of indicators in time; clinical software in use in general practice neither shows the current indicators. General practitioners need to look for information not easily available to know what they are supposed to be doing today when reviewing their patients.

-There are inadequate indicators: Once again, despite clinical review, indicators of questionable clinical value remain [3]. For example, although indicator “RA002. The percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face review in the preceding 12 months” for a patient on methotrexate could be beneficial/acceptable [4] it can be argued there is no benefit for the many patients on no medication, some asymptomatic for years, some of whom already have a yearly check-up in secondary care, causing a waste of time to patients and clinicians.

-There are inadequate targets: The agreement between NHS England and GPC England “to replace the current blunt system of exception reporting with a more precise ‘personalised care adjustment’ “[2; page 21]. It is to be questioned if the retirement of indicator “DM007. The percentage of patients with diabetes on the register in whom the last IFCC- HbA1c is 59 mmol/mol or less in the preceding 12 months” with a range 35%-75% is properly substituted with the new indicator “DM020. The percentage of patients with diabetes without moderate or severe frailty on the register in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months” and the same range. It implies simply all the patients with frailty that were perhaps removed before as “exception reporting” are no longer there, making the new target much harder to achieve. There has been no consideration on the impact of frailty on the tight management of diabetes. It seems the goal is to penalise GPs

These are just a few examples of current issues with the new QOFs in England. It is likely that primary care in other countries of the United Kingdom are laughing at the fact they already removed QOFs and the political game it has become.

References
1. Vautrey R, Dodge, I. (2019). Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan. Accessed on April 1st 2019 from https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf
2. NHS Employers. Quality and Outcomes Framework. Accessed on April 1st 2019 from https://www.nhsemployers.org/your-workforce/primary-care-contacts/genera...
3. Millares Martin, P. (2014). Quality and Outcomes Framework indicators should not be used without proper clinical evidence. BMJ, 348(Apr03 1). doi:10.1136/bmj.g2373
4. NICE Quality and Outcomes Framework indicator (2012). The percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face review in the preceding 12 months. NM58 indicator development feedback report. Accessed on April 1st 2019 from https://www.nice.org.uk/Media/Default/standards-and-indicators/qof%20ind...