Doing Family Medicine Better
An academic career focused on improving patient care, exploring structures and systems, and understanding the interplay of multiple illnesses.
Chris Salisbury is Emeritus Professor of Primary Health Care at the University of Bristol. He describes himself as having had three overlapping careers: as a full time GP for more than 10 years, then as an academic doing research and teaching alongside general practice, and finally as a leader and manager. His academic work has focused on how to ‘do family practice better’ and the impact of new models of care, including changes in GP out-of-hours arrangements, NHS walk-in centres, Advanced Access, GPs with Special Interests, the expansion in clinical roles in general practice, continuity of care, digital care and remote consultations, and improving the management of patients with multiple long-term conditions.
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“At first I thought I was going to be an architect. And then when I started sixth form, I thought I was going to be a vicar. I went to speak to my vicar and he said, “You’re far too young to decide that. Go and do something else for a bit.” And I thought, medicine sounds like that kind of caring, good thing to do. So I did that, and I never thought about being a vicar again after that. I took to medicine and I love it.”
The Health Centre in Reading
Let’s take you back to the very beginning. What stimulated your interest in medicine?
Chris Salisbury: It was quite a late thing. At first I thought I was going to be an architect.
And then when I started sixth form, I thought I was going to be a vicar. I went to speak to my vicar and he said, “You’re far too young to decide that. Go and do something else for a bit.” And I thought, medicine sounds like that kind of caring, good thing to do. So I did that, and I never thought about being a vicar again after that. I took to medicine and I love it.
DMacA: So you went to medical school and then you did family medicine. Tell me about that decision.
CS: Again, that wasn’t straightforward. I thought I wanted to do psychiatry. I started on a psychiatry training program and did that for a year. But, I missed medical patients, such as when an old lady got a chest infection on the ward, where I thought I was being a proper doctor. Psychiatry at that time felt very different from medicine and it was also a bit slow. I’m a bit impatient. I like to be doing the next thing. I like action and moving fast, so then I didn’t know what to do. And general practice sounded like it had a bit of everything. It gave me a chance to stay in one place and not be doing six month contracts all over the country. Once I started doing it, I realized this is the thing for me but it wasn’t a particularly well thought out decision to get into general practice.
DMacA: Looking back to that particular time, those were really exciting times in family medicine.
CS: Absolutely. Family medicine was the top choice for many people’s career. I was in Bristol, I loved Bristol, I wanted to stay here, but everybody wanted to be in Bristol and everybody wanted to be a GP. And I knew really bright people who were hanging around doing locums in Bristol waiting for a job to come up. I couldn’t do that, my wife was pregnant, and I needed a job. So, I took the first good job in a university town in the south of England. It was in Reading and there were 100 applicants for that job. It was a time when everybody wanted to be a GP and there was a lot going on. I threw myself into that and there were lots of things to do. We computerized the practice and built a new surgery.
I had been to a great talk in Oxford, by Barbara Stilwell who was a pioneering nurse practitioner, and we introduced a nurse practitioner. She and I wrote a book together, a sort of handbook on how to employ nurses and how to run clinics and minor illness management for nurses. And that was a big success. That gave me the buzz of operating on a bigger scale than in my own practice.
DMacA: Talk to me about nurse practitioners and enabling nurses because this was widening the team, which is very controversial in the UK at the moment in the context of
physicians assistant. You were pretty much ahead of your time.
CS: Yes. And I wrote an editorial. I think it was in the BMJ although it might be in British Journal of General Practice about the idea of nurses being partners. There was resistance from nurses about the idea of being employed by doctors. I was quite in favour of a multidisciplinary team running the practice so that it was the team that ran the practice rather than just doctors. But I do understand the concerns these days. One thing I’ve learned is that bringing different people into the team brings different skills but we shouldn’t pretend they’re all the same and they can all do the same things. They don’t so much take over things that GP’s do, but provide a different range of skills for things that GP’s weren’t previously doing. It’s one thing, for example, for physiotherapists to do musculoskeletal work but I wouldn’t have physiotherapists managing undifferentiated patients with minor illness. I think that quite a lot of the people being brought into general practice now are not appropriately trained to do the things that they are being asked to do. It’s not a criticism of them. There are probably some good people doing their best. But I don’t think we should place people in jobs that they are not the right people to do
DMacA: There’s a big difference between the practice nurse and the nurse practitioner. Can nurse practitioners see patients on the first line?
CS: Yes, I think they can. As long as they know their limitations and they know the things that they’re not good at, and they’ve got a good relationship with the doctors and can talk about things. I don’t think you have to see a doctor for everything, for every health need.
But, I do think there are things that doctors are good at and things that nurses are good at. When I started general practice nurses weren’t terribly well trained to do general practice, but nor were doctors, in fact nor was anybody. They’d been trained to do a very different job, and then they were placed in this environment. I don’t think that we really trained people then to do the range of things that general practice needs.
DMacA: Just a moment ago you mentioned a knowledge and skill that has disappeared. That is that you built a new surgery. That was an adventure.
CS: That was, absolutely. That was one of the highlights of that part of my career. There was a scheme where you could get help with the interest on a loan. And we took a one million pound loan. It was 1989, a million was a big risk. We built this fabulous building and it was a really exciting project. It soaked up all my spare time thinking about windows, talking to the architect, visiting surgeries around the country to get ideas about what we wanted to do. I like projects, in fact, that’s one of the things that gets me into research. It’s not just research. It’s having something to build, to work on, to make a product.
DMacA: So then you move to Bristol. Tell us about your move to Bristol.
CS: It wasn’t quite like that. I was in Reading but I always had this sense that I wanted to keep my career developing and I went to do a Master’s degree at United Medical Dental Schools, now King’s, and that was the turning point. There weren’t many Masters courses and this was set up for future leaders. There were just 12 of us. It was all about research and teaching and I learned about research methods, statistics, adult learning theory and educational methods, medical ethics and scientific philosophy. It was a bit like an encounter group where there were just 12 of us. We would talk about a paper, we’d present it, discuss it, and talk about what it meant to us in our practices. We’d critique the methods, and while it wasn’t as advanced as the research training that some of my young colleagues now have at the London School of Hygiene or wherever, it was really broad training, encouraging us to think and write essays. I can remember the first essay I wrote was discussing the problem of trivia in general practice. I had to read the early sociological research about why GPs feel what they do is trivial. I just loved it and I found I was good at it. And my thesis, which was on how people choose their doctor, got published in the BMJ. And it was so exciting as a master’s student, to have your paper in the BMJ, which was a big thing. It’s fun being part of a big conversation. There was quite a lot of controversy with my paper and, being part of a controversy, I enjoyed it as well.
“One thing I’ve learned is that bringing different people into the team brings different skills but we shouldn’t pretend they’re all the same and they can all do the same things. They don’t so much take over things that GP’s do, but provide a different range of skills for things that GP’s weren’t previously doing.”
“I love Bristol as a place. It’s just such a vibrant arty place.”
DMacA: The Masters obviously set you up for your career and encouraged you to take the next step.
CS: And I really wanted to do it, and I kept applying for jobs and didn’t get them. I kept losing out to people who were already in the university system, already had a PhD and were lecturers or whatever. I applied for several jobs, didn’t get any of them, eventually applied for a job that I really thought I was well set up for in London. I didn’t get that either, but Brian Jarman was on the interview panel and phoned me afterwards. He said, I’ve got someone who wants to go part time and needs a job share. And that was in London at Saint Mary’s, and I did that. That went really well for three years and that’s what enabled me to get my job in Bristol, which is what I’d really wanted all along. That’s was in 1998 when we got back to Bristol.
So, if any younger colleagues watch this and feel disappointed when they don’t get their first choice of things, it was a torturous route for me and for many people. It comes right in the end, but you might have to try a few things before you get there.
DMacA: After all these hiccups and hurdles you’re now in Bristol. Tell us about that.
CS: I love Bristol as a place. It’s just such a vibrant arty place. I love the university, partly because it’s a very wide-based university with humanities as well as sciences, and it is a very cultural place because the BBC is here and there are lots of media companies here. You constantly meet interesting people who think about things. I have so many colleagues that I just love talking to and they have so many interesting ideas. It was a good place to come to. Debbie Sharp was the Head of the Department and she’s full of energy and ideas and was driving it forward.
Tom Fahey, was the other senior lecturer at the time, a really great guy. And, we were very successful between the three of us and a few other people as well. We applied for lots of grants, got lots of projects off the ground, and the department grew and then eventually became one of the leading departments that formed the NIHR School for Primary Care Research. And we are very pleased that we’re one of only two places, I think, that have been re-appointed through multiple renewals ever since. I’m really proud of our department in Bristol. It is, I think, one of the leading primary care departments in the UK, which probably means in the world. it’s a great place to be, a great place to live and a great department.
Its part of a bigger unit now with Population Health, where we’re working with world leading epidemiologists and statisticians and public health doctors and that’s been a good development as well.
DMacA: So you developed your research career and you have a lot of different interests. What were the ones that you started with?
CS: Because of my background, I was 13 years as a GP – ten as a full time GP and three as a part time GP- and I was always interested in trying to run a good practice, responding to consumer’s needs, providing good quality care, and efficient. I was trying really hard to run a responsive practice that provided good care. And therefore I got involved with things like nurse practitioners and computerization and good buildings so a lot of my projects have been about how to do general practice better. I think that’s the common theme. They’ve often been organizational things and thinking about the implications for general practice of new models of care. Quite often politicians come up with an idea saying, “I know the problem we just need to do this and it’ll all be fine”. And I’m thinking it’s not as simple as that and then I try to evaluate the pros and cons of whatever that may be. Walk-In centers is a good example. ‘Oh, we can’t get a GP, so we’ll just set up this parallel service next door, Walk-In centers.’ We evaluated that looking at the pros and cons and what the impacts would be on general practice.
DMacA: But it wasn’t just the academic side of things. You were very grounded in practice and it wasn’t in a leafy suburb, it was in a more deprived area.
CS: Absolutely. In Reading I’d worked in a very mixed area from quite poor areas in the centre of town to affluent suburbs. But in Bristol it was a kind of condition of the job. The health authority put money into my job on condition that I went to work in this very poor, deprived part of Bristol, in a big council estate in South Bristol. But that was really good and I had some very good partners there. Other people who were also fairly new there were determined to do something about health inequalities and to provide good care in an area that had generally not had such good care before. And the Health Authority put money into developing a healthy living centre – not just medicine, but a community garden and exercise facilities and things like that. We really did develop a good practice, which was actually not much to do with me, because at that point, most of my energies were in the university. But the health authorities were pleased because their strategy of linking academia to health care seemed to work. In reality, it was other people in the practice, but everybody was happy. I did learn a lot about how different general practice is and how being a GP in a deprived inner-city council estate is very different from working in a rural practice, not that I ever worked in a rural practice, but I now know a lot more about the range of general practice.
DMacA: And there was another area in which you were involved, palliative care, and you wrote a book.
CS: Yes. When I was in London I was working with Nick Bosanquet, who was a health policy expert, but that didn’t prove to be an enduring theme of my research. It was a research grant where they wanted a systematic review of all the evidence about different ways of doing palliative care. And I was new and keen and had never done a systematic review, put lots of effort into writing the grant proposal and we got it. And then the Oxford University Press asked if we could turn this into a book, which we did, but I haven’t done more palliative care since then.
“I love Bristol as a place. It’s just such a vibrant arty place. I love the university, partly because it’s a very wide-based university with humanities as well as sciences, and it is a very cultural place… You constantly meet interesting people who think about things. I have so many colleagues that I just love talking to and they have so many interesting ideas.”
DMacA: Let’s move on to a more enduring theme which has been your work on multimorbidity, tell us how that began and how it evolved.
CS: It began because the Quality and Outcomes Framework, or QOF as we call it in England, was introduced in 2004 and it set out particular targets and things you had to do within a range of the major chronic diseases. At that point, people would come in with back pain and my computer would be flashing up that you must take their blood pressure, you’ve got to check their diabetes, you got to check their asthma. And it just felt like everybody that I was seeing seemed to have multiple diseases and also it was distracting me from concentrating on the thing that the patient wanted to talk about. That struck me as a problem, but also interesting. So, the first thing I did was just to count and find out if it was true that everybody has lots of conditions. And what we found was that about 16% of the population were on multiple disease registers but that they took up about a third of all consultations. They were disproportionately having a lot of consultations and I also felt these were the people who most needed a relationship with the doctor. But, we looked at continuity and found that they were the least likely to get it because they were seeing all these different people. I submitted it to the BMJ and it was rejected by the BMJ, got published in the BJGP and got a modest amount of attention. But the following year, Bruce Guthrie and his team published a very similar paper in The Lancet, which got massive publicity. So, I’ve never quite forgiven the BMJ for that! But, again, it’s another example about how some things work out and some things don’t. And anyway, Bruce’s paper was probably better in a number of ways, because it told a more interesting story. And I was fortunate that that was the beginning of a crest of a wave that has become a huge topic. And it came from me as a GP just feeling that everybody seemed to have lots of things wrong with them and that we operating in a system that wasn’t really catering for this. We were treating people as if they had just one thing, and we were designing a system that was for short consultations for single problems. If you really want to respond to people’s needs, you needed longer consultations and you needed to focus GP’s time on these complex patients who actually take up most of the consultations.
DMacA: So that evolved from painting the picture of multi-morbidity, to go on to run trials.
CS: I did a number of other things around multiple morbidity; we looked at the economics, and a systematic review of ways of measuring multimorbidity, because there’s still an ongoing discussion about what exactly is multimorbidity and how do you measure it, more stuff around the epidemiology and concepts and so on. But I’m most interested in how can we make care better. I was at a GP training event where I was speaking about something completely different and a GP got chatting to me over lunch and said, “what we do is we don’t do these separate clinics, we just get people in once and we do a whole person review.” And it struck me straightaway that it was such an obviously good idea, why don’t we all do that. And, then I did an event at the Royal College of GP’s annual meeting where I asked people to think – imagine your mother has got diabetes and early dementia and a bit of heart disease, what care would you want for her? And I got people to talk about what care they thought we should be trying to do. And I think it was obvious to everybody that what we were doing wasn’t actually what people needed. I tried to develop an intervention that would be like that, and that turned into the 3D intervention, which turned into a trial, which turned into a paper in The Lancet, which is widely interpreted as being negative, but I don’t see it as entirely negative. It was negative in that it didn’t improve people’s quality of life. But then hardly any organizational interventions in trials ever do, but it did show that on multiple different measures, it gave people care in a way that they wanted, that they felt met their needs, that reflected the kind of care they wanted, and that they were able to talk about the things that matter to them- lots of different measures of patient experience. Both patients and doctors seemed to like it, and it didn’t cost any more, and it didn’t generate any additional work. In all those measures I see it as a partial success and I’m still pursuing that idea in a current study, trying to understand how to overcome the barriers to implementation of this kind of work.
“It began because the Quality and Outcomes Framework….And it just felt like everybody that I was seeing seemed to have multiple diseases and also it was distracting me from concentrating on the thing that the patient wanted to talk about. That struck me as a problem, but also interesting.”
DMacA: As a final question, the department recently organised a Festschrift to celebrate your career, that must have been a great thrill.
CS: It was actually lovely. I was worried that it would be a bit embarrassing and cringeworthy but, actually, it felt more like a wedding with all your friends there, people you’ve known over your working life who are there to wish you well and celebrate. And there were some great talks from some of my colleagues who I’ve worked with for many years and they all gently made fun of me. If they had taken it terribly seriously and listed all my achievements that would have been embarrassing. But they made fun of me and talked about things that I do and things they’d learned. And I did a few reflections on academic life, and everybody seemed to enjoy it. I enjoyed it, and I’m grateful to them for organizing it.
CS: Chris, as always, it’s been great fun talking to you, and it’s been a lifelong pleasure to have shared our careers along parallel tracks. Thank you very much indeed.
With colleagues, Professor John Campbell (Exeter), Professor Bruce Guthrie (Edinburgh), Professor Helen Atherton (Southampton), and Professor Matthew Ridd (Bristol)
