Jennifer Raiman (Macmillanâs Medical Services Director) had done some research on GPs, which found that they were pretty awful at palliative care. She came and challenged the RCGP, and the chairman passed her letter on to me. So in late 1989 we all sat down together and asked âWhat are we going to do about this?â, and there were subsequent meetings through JanuaryâFebruary 1990 (as with all these things, nothing ever comes of one meeting). (Ivan Cox)
This description of change emerging through a series of specific conversations is very pertinent to our story, because it reflects one of our fundamental premises ânamely that change emerges from people talking to each other (conversation or dialogue), not just from plans and programmes. It took another two years of meetings and written proposals before all the parties concerned were ready to act. But finally, in 1992, the RCGP General Practice Palliative Care Facilitator Project was launched. In essence, this offered âprotected timeâ (funded by Macmillan) to six GPs with experience of or an interest in palliative care, releasing them from their clinical responsibilities typically for one day a week. These individuals were based in different parts of the UK and remained practising GPs employed by the NHS, but they could use their protected time to develop their own skills, raise awareness about cancer and palliative care, and provide education, advice and support for other GPs. In addition, they could take steps to improve collaboration with hospitals and specialist palliative care providers (e.g. local hospices). The GPs chosen were known as Macmillan GP Facilitators, but throughout this book we refer to them simply as âMacmillan GPsâ.
It was during these early years that the âpractice visitâ became established, whereby Macmillan GPs travelled around discussing palliative and supportive care with primary care teams in their area. They also developed educational material on controlling symptoms and communicating with patients, and they helped compile cancer and palliative care registers and directories of local services.2 Following the pilot phase, in 1994 Macmillan and the Department of Health agreed to âroll outâ the programme by establishing GP Facilitators across the UK.
As the community began to grow, Jennifer Raiman argued that Macmillan should also appoint âGP Advisorsâ (GPAs), who would work closely with the funding organisation and keep in touch with the growing number of GP Facilitators on the ground. The idea was that this would increase Macmillanâs ability to influence the national debate on cancer care. In 1994, following further discussions with the RCGP, two Macmillan GP Advisors were appointed (David Millar and Ivan Cox). Their funding covered two days a week each plus administrative support. For the next five years, they travelled the UK recruiting and educating Macmillan GPs.
The GPs were âMacmillan-badgedâ. After their Macmillan-funded protected time came to an end (typically it lasted three years), many found local funding to continue the work, but they continued to refer to themselves as âMacmillan GPsâ and remained connected with the charity and its GP community.
Early evaluations of the Macmillan GP community
Early evaluations gave a sense of the wide-ranging activities pursued by Macmillan GPs in the first decade. One study showed that activity reflected different local contexts and preferences. Much was educational, including courses on topics like âbasics of palliative careâ and multidisciplinary meetings on âbreaking bad newsâ. A key element was visits to other practices, enabling Macmillan GPs to hear about problems faced by their peers and to help them find solutions. Networking with fellow professionals and working on guidelines were also common.3
Moreover, relationships between the GPs and their specialist palliative care colleagues had improved, making it easier for GPs to access specialist knowledge. This âbridge-buildingâ was seen as crucial, because one of the main barriers to continuity and quality of care had been poor relationships between GPs and their colleagues in hospitals.4
Another evaluation, undertaken in Wales between 1999 and 2002, found that each of the 17 Macmillan GPs interviewed âhad added substantially to their knowledge and experience of palliative care and palliative care education, the majority to the extent of successfully completing a university diploma in palliative medicineâ.5 Moreover, the very existence of Macmillan palliative care GPs in Wales âhad brought the issue of palliative care into the spotlightâ.6
An article published by two Macmillan GPs in the journal Palliative Care Today in 2001 gave tangible examples of the ripple effects of the community, e.g. a debriefing for a troubled district nurse following the care of a dying child; round-table discussions with two neighbouring hospices who had not talked for 10 years; an increase in appropriate referrals from practices; and gentle support given to a burnt-out GP encountered on a routine visit.7
Macmillanâs sponsorship enabled the Macmillan GPs to meet one another not just through practice visits but also at community meetings (they gathered regularly as a group from the beginning), where they could share stories, problems and solutions with one other, develop collaborative projects and work out how to influence healthcare policy. These ways of working were in a sense natural to doctors â it was they themselves who pointed out that âGPs only listen to other GPsâ.