17 November 2022: Mulholland - A

Dr Mulholland is a practicing GP and Honorary Secretary of the Royal College of General Practitioners. The College exists to foster and maintain the highest standards of GP working. He has the main governance role, supports the membership team, and oversees policy.

All GPs enter a training scheme with the College setting the curriculum and overseeing exams. There are then areas of post-exam training on more practical work. The process of becoming a GP happens at a UK-wide level which link to GMC systems. The special skills covered include communication at all levels. A three-part exam includes clinical skills assessment, communications skills assessment, and workplace-based assessment. There are GP trainers and GP assessors. GPs must clearly know what they are doing to manage the patient’s needs, interpersonal skills, and attitudes, feelings, and biases. They use videos, simulations, case studies, reflection and more as part of the training.

Deaneries are the regionalised structures for training – the four nations education bodies. They work with the training bodies. The College also provides continuing professional development (CPD) materials freely, but it does not set the individual programme – that is for the GP and their appraiser. Webinars and other channels are used occasionally, but much of the learning is self-directed. The topics are very wide covering all aspects of being a GP.

Counsel asked about the particular issues for women whose HCV diagnosis was delayed after being put down to motherhood or menopause. The witness said this should be covered in the overall equalities focus, including the recognition of potential biases. The witness could not say if there was specific training material on women and their experience of pain. He did know there was material on race discrimination.

There are 54,000 members of the College. NHS England appoints external appraisers to ensure CPD is happening. Topics covered by CPD are selected in part from self-reflection, part from colleagues and part from patients. There is a risk of GPs not receiving the CPD training they need through these means. Communication skills is mostly covered in the five-year multi-source feedback process. If there are issues with a GP and their development or practice it is likely to be referred to the local responsible officer.

It was recognised how there were great amounts of guidance updates coming to GPs constantly. Some publications will summarise guidelines which makes it easier to access the most relevant parts. The witness was not able to say how things happened in Scotland, when asked. The adoption of improved practices is not prescribed by the College, but issues can be reviewed and checked in audits.

The College has been producing materials on HCV since 2006/7. They have training modules and other resources. Reference was made to guidance produced by the College. Counsel commented that it seemed to focus on haemophilia and overseas transmissions, but not blood transfusion infection. The Chair picked up on an inaccuracy in the document about the timing of key developments. It was put down to being an older edition, but since the Chair pressed the matter the witness committed to ensure it was checked and changed if necessary. It was discussed that GPs may not have had the information, say 15 or 16 years ago, when documents were being produced, but the witness felt that nowadays there was much more understanding and appreciation of the Hepatitis issues. Another example of the wrong dates was noted from the document which required to be checked. It was also acknowledged that older medical records were often incomplete, and it was not always the case that GPs got to know if, for example, one of their patients had received a blood transfusion.

Noting that a patient had an abnormal liver function test might be seen by a GP as a reason to carry out a test for HCV, but it might not. Such as result would more likely spark investigation into fatty liver issues and alcohol misuse problems. On the scenario of a patient having undergone antiviral treatment and achieved a sustained viral response, it appears that the guidance suggests that healthcare on that matter simply ends for the patient. The witness recognised how much the treatment of HCV had changed, and there would be a reliance on secondary care colleagues to be leading on the care of such a patient. GPs would expect to receive information about what follow-up was required. For the GP there is a focus on the holistic care of the patient while specific diseases and conditions would be managed by secondary care. The witness was aware of specific material on viral Hepatitis due to the higher incidence of IV drug use, but beyond that he did not know of any other material directed to GPs.

The Chair noted the document had a strong focus on IV drug use. The witness admitted that this was the major concern for GPs when it came to HCV at the time. The Chair then suggested that it could have led to people who had been infected via contaminated blood being treated as if they were an IV drug user or an alcoholic, perhaps as an unconscious bias, in part as a result of the listing on that document. The witness agreed that could happen, with transfusion not being considered as an explanation for the presenting indicators.

Recognising how there remains a considerable knowledge gap among GP about HCV, Counsel asked the witness what he thought could be done to improve the knowledge and awareness of GPs. The witness thought the awareness was greater these days, including by his appearance at the Inquiry as a further spur to make the link with blood transfusions and products. Some focused work has happened for Scottish GP  but that again is related more to the higher incidences of IV drug use, and it is something GPs are seeing all the time. Overall, he was not sure what could be done but it was something for the College to consider. He did say that patients come in all the time with symptoms which need to be diagnosed, and there is a step-by-step process GPs go through. Maybe the publications can be changed to include the consideration of HCV when a raised ALT is noted.

A scenario was presented of a patient asking to be tested but the GP saying it was not necessary because of the look-back exercise. However, the Inquiry had evidence of the weakness of the look-back. Again, the witness thought the awareness was much better now. But, he recognised that there would be gaps in the records GPs had. He spoke about the possibility of adding a question to the first screen of the electronic platform for a new patient to record if they have ever had a blood transfusion – the same way they ask about weight and alcohol intake. On the look-back shortcomings, he was not sure any awareness-raising would be just for GPs.

Another scenario was that of a patient who felt there were HCV-related concerns remaining after they has achieved a sustained viral response, but the GP dismissed this due a lack of appreciation of the wider impacts of HCV. The witness was asked how the need for ongoing care and monitoring could be brought to the awareness of GPs. He thought some of their newer training material covered the issue, so it could be picked up as part of a GPs CPD. It was suggested that as well as a knowledge gap there might be a culture factor, so he was asked how that might be overcome. There was a resistance to mandating learning (apart from resuscitation training and safeguarding). The witness intended to notify his members about his appearance and use that as a learning opportunity on these matters.

The final matter was one of identification of undiagnosed people through GP surgeries. The witness saw that as requiring additional resources. They are already over-stretched and under-resourced.