“I’ve been fortunate to have a career doing academic general practice…… it’s a portfolio career, and that’s been one of the things I’ve really appreciated.”
Professor Philip Evans FRCGP is an academic GP and was for 31 years a GP partner in St Leonard’s Practice, Exeter. He has a long-standing research interest in relational continuity of care in general practice, as well as prediabetes/ type 2 diabetes and more recently primary care genomics.
He is currently National Associate Director of Health and Care Research in the NIHR Research Delivery Network (RDN) and was previously the NIHR CRN National Specialty Lead for Primary Care. During the COVID-19 pandemic he was Deputy Chair of the NIHR Urgent Public Health (UPH) Group and has recently led the CRN engagement with the four-nation PRINCIPLE and PANORAMIC studies of community-based treatment of COVID-19. He has over 28 years’ experience of leading primary care research networks, both locally and nationally. For the last four years he has been leading the NIHR CRN Primary care Research Strategy.
Emilie Couchman is a salaried GP with the Sarum Health Group in Wiltshire. She considers her clinical remit to be generalism and is a firm advocate of continuity in clinical practice. Emilie is an NIHR Clinical Lecturer in General Practice with the Division of Primary Care Palliative Care and Public Health at Leeds University. For the past 16 years, her academic field of interest has been palliative and end of life care. She is married to a resplendent man and they have two young children and a middle-aged Hungarian Vizsla.
I’m Dr Emilie Couchman, and today I am talking with Professor Phil Evans. Phil is a proud Welshman, and a passionate Wales and Exeter City football fan. He plays five-a-side football, enjoys cycling and is a keen photographer. Phil is a retired GP, having been a partner at St Leonard’s Practice in Exeter for 31 years. He is currently the National Associate Director of Health and Care Research in the NIHR Research Delivery Network, and has over three decades of experience of leading primary care research networks, both locally and nationally. His key interests are relational continuity of care, and the management of pre-diabetes and the prevention of type 2 diabetes.
Might we start with your childhood? Was your future career influenced by your family or your schooling in any way?
Philip Evans: It was actually, Emilie, yes. My father was a doctor, and I suppose I’ve always wanted to grow up to be a doctor, if you think about it when you’re a kid like that! My father was a consultant paediatrician, and a part-time academic. In our house, we sort of ‘lived’ medicine. He worked long hours, worked Saturdays, as a consultant in Wales, and I grew up in that sort of medical environment. Now, none of my family became doctors, but I did. I think I liked the approach. We used, for example, to have the Lancet on the kitchen table occasionally or, like the BMJ in most medical homes, I used to pick it up and read it and think, ‘I’d quite like to do medicine, actually!’ And my father very much saw it as a vocation. He didn’t push me into medicine; my parents didn’t push me into medicine at all, but I think when I was going through high school and realising that I liked science and I wanted to be in a caring profession, then I took up medicine. This was a long time ago, in the 1970s! So, I went into medicine, probably as a consequence of just being around him. He also used to take me into hospital occasionally to see the ward, and meet the staff and, you know, the environment becomes medical. Not everybody wants that, but I obviously did and went for it.
EC: And your two key interests are continuity of care and diabetes, prediabetes. Might we first discuss how your affinity with the diabetes prevention and management came about?
PE: I’ve been fortunate to have a career doing academic general practice, and I’ve always found that it’s been a great mix, of actually doing the academic work alongside the clinical work. So, it’s a portfolio career, and that’s been one of the things I’ve really appreciated. I’ve increasingly done more academic work as I’ve gone through my career, but being grounded in clinical reality, I think, has been absolutely key to this. So, when the 1990s came, we realised there was some really important work going on around the prevention of type 2 diabetes. So, when people first said to me, ‘oh, you can prevent type 2 diabetes!’ that was quite a game changing discussion, you know? We were showing that lifestyle interventions were actually better than pharmacological interventions in preventing type 2 diabetes, and I had a lot of patients in those days with slightly raised high blood sugars. It just made me think about what I do with these patients. In fact, a lot of my research has come out of that reflection from the clinical practice and then thinking, ‘well, where is the literature around this?’ And there were big randomised controlled trials coming out, particularly in Finland and the US, around how you can prevent type 2 diabetes. I acknowledged that, and took it on board as a key thing that I could be doing with these individuals, working with them on lifestyle management etc. So, I then started to get into what was then called prediabetes in some studies, but it was very much a new concept. So, I got to understand prediabetes and with colleagues here in Exeter, we started to work with patients and doctors to understand their understanding of what was a relatively new condition, but also there was the great potential for preventing type 2 diabetes. So, I’d also done some work in the practice around opportunistic screening for type 2 diabetes. So, the sorts of things that GPs are doing every day, ‘for this patient, why don’t we do a HbA1c and see? Why don’t I just exclude type 2 diabetes in this individual?’ But in those days it was a fasting blood glucose. We’d been doing a lot of retrospective work looking at how the vast majority of our patients with type 2 diabetes were picked up in our practice by opportunistic screening, following protocol-driven care, and advocating that as an alternative to population screening or now the work that’s done in the NHS Health Check, for example. So, we got into opportunistic screening and we published around that, the cost, as well as the outputs, and then how you work with patients. We did an action research study called the ’Wake Up’ study around prediabetes, and that was working with patients and getting a feel for their understanding in a qualitative way, but also working with GPs and again, in a relatively new condition. So, I was fortunate enough then to carry that on, and did some work on international guidance around how you prevent type 2 diabetes. More recently I’ve got into ‘remission’. I went to a meeting that Diabetes UK had convened just after I stopped clinical practice, and again, was really enthused by patients who were losing large amounts of weight with help and support, and going into diabetes remission. I was fortunate enough then to be picked up for the international consensus work around diabetes remission. So, type 2 diabetes has been a thread through my academic career. It’s a really significant disease to me, and I have had family members with type 2 diabetes, so, the drivers for these sort of things are really important.
“I think the role of the clinical generalist is relatively poorly understood. I think that’s part of what we’re not very good at; expanding and articulating what the role of the clinical generalist is. I think we need to do more of that.”
EC: Has there ever been any tension between whether you see yourself as a generalist and, the wealth of experience you’ve got in something as specific as diabetes. Do you ever feel tension between, ‘am I a generalist or am I a specialist?’ Do colleagues send diabetic patients your way, when you’re in clinical practice, for example?
PE: I’ve always seen myself, first and foremost, as a generalist, but I think, the vast majority of generalists have areas where they are slightly more specialised than others. And I think this was an area where I was specialised. But yeah, patients in the practice, my partners used to send me, not necessarily patients with type 2 diabetes, but prediabetes patients, to think about prevention. That didn’t happen a lot, it was just something that I was interested in, and it added a lot to my clinical practice because these are common conditions. So, if you’re seeing a lot of people with raised HbA1cs – what do you do with them? And how would you advise those patients? I didn’t really see myself as a GP with an extended role, for example. In those days, they didn’t exist. I just felt that it also gave me an interest and, having had quite a specialist medical education, I think I was sort of unlearning most of that when I became a generalist GP in those heady days in the early 1980s. But also it encouraged me to think about which areas I’d quite like to specialise in. It’s women’s health for some people, it may be cardiovascular disease prevention for others, but this was just something that added to the skill set that I had, which was good.
EC: How do you feel about generalism in general practice as it is now? Do you think it’s something that we need to preserve, or do you think that we’re heading in a direction where GPs are increasingly subspecialising, and, the MDT [multidisciplinary] nature of everything is going to compromise generalism in some way?
PE: I think we [GPs] are at our heart, clinical generalists. We’re specialised in generalism, and I know that’s always the approach that I’ve taken. I think the role of the clinical generalist is relatively poorly understood. I think that’s part of what we’re not very good at; expanding and articulating what the role of the clinical generalist is. I think we need to do more of that. I mean, some colleagues have done some excellent work on that. But again, to the average layperson, the complexities of handling multiple conditions in the same patient or the relationship between the biopsychosocial issues around the patient are relatively poorly understood. So, I suppose we’ve got to advocate more for the generalist role. I’m convinced by Barbara Starfield’s excellent work around primary care more widely and internationally, but I think the role of the generalist needs to be better stated. In terms of its economic value, the efficiency of general practice, the productivity of general practice; is phenomenal. It has always struck me, the ability of GPs, even in the short time they have with patients, to be productive in terms of health service provision. It’s really important, but I think you’re right, I think it is threatened. But on the other hand, we need to be extolling it more as the most cost-effective way of delivering health care. I mean, you can very rapidly become deskilled as a generalist, and I think if you’re self-aware as a GP, you rapidly realise that. I used to do a lot of women’s health when I first started general practice, but less so as I got older as colleagues who came into the practice are far better experienced than me at dealing with women’s health problems. So, inevitably you get deskilled, even with diabetes, COPD and chronic disease management, as so much of that is now done by the practice nurse. So, there’s a need for updating yourself regularly, and I think academia and research helped to me to do that. And obviously continuity, relational continuity, is absolutely central to generalism, hence my interest in that over the years.
“And I think that contrasts with specialists who are seeing, relatively, the same condition in different patients. We are seeing, of course, different conditions in the same patient.”
Randomized controlled trial of molnupiravir SARS-CoV-2 viral and antibody response in at-risk adult outpatients. Nature
Molnupiravir plus usual care versus usual care alone as early treatment for adults with COVID-19 at increased risk of adverse outcomes (PANORAMIC): an open-label, platform-adaptive randomised controlled trial. The Lancet
Cost-utility analysis of molnupiravir for high-risk, community-based adults with COVID-19: an economic evaluation of the PANORAMIC trial. BJGP
EC: You’ve collected a number of qualifications along your career path. Which one means the most to you and why? You might need a moment to think about that!
PE: I was delighted to be appointed as a Fellow of the College [Royal College of General Practitioners] in the UK. It’s always nice when colleagues acknowledge you – peer evaluation is always important- recognising the achievements that you’ve made in your career. Research qualifications and educational qualifications aside that, to me, was probably one of the best parts of my career.
EC: You seem to embody the term ‘lifelong learning’. How do you feel about that phrase? Do you have any plans to actually retire at any point, or what’s the next study that you’re going to undertake?
PE: I do subscribe to lifelong learning! Every day is a school day, and I think as a clinical generalist that is definitely the case. I’m now over 40 years now as a doctor, but even after 30 years as a GP, there were still conditions, and situations you found yourself in, where you didn’t know what to do. That is the intellectual challenge of general practice, if you like that challenge! And I think that contrasts with specialists who are seeing, relatively, the same condition in different patients. We are seeing, of course, different conditions in the same patient. So, I think, yes, I may retire, but I like the sort of cut and thrust of new things, and actually, moving away from clinical practice has allowed me to do more in terms of research and the other things that I would like to do; leading research and research delivery, particularly. So, every day is a school day, and I think being humble enough to acknowledge that is key. When I look back at how I was as a young junior doctor, and how you felt that you knew most things, but experience is very important here, then you see atypical presentations of everything as you go through your medical career. That leads you then to question precisely what each diagnosis is. So I think, yes, it’s life-long learning. And I think the key thing I found is having partners that you could share those uncertainties with, and having the opportunity in an MDT, or to meet with your partners just to share conditions. I was also part of a Balint group – I was fortunate enough to be part of a Balint group for 30 years which was, again, a remarkably supportive environment to bring those really complex, anonymised patients to. if I was completely stymied by a presentation, or what to do in a complex case, I felt supported by that. So, every day is a learning day, but you need support, and you need help, and you need people you can turn to, to do that.
EC: And, moving towards the primary care research network role that you’re currently in, and obviously, having three decades of experience in that area, how does that fit in with your clinical academic career? Where does the research network fit?
PE: Over 30 years of leading networks… When I first had an academic post here as a lecturer, which was 30 years ago now, it was to lead the nascent research network in the South West. In those days, research was seen very much as a sort of, amateur sideline, a ‘corner shop’ type thing! There were some great enthusiasts – people who were evangelical about research, which was great. But my colleague, Paul Wallace, talked about professionalism of research in primary care, and at that time, it was very much a sort of, sideline hobby rather than a professionalisation of primary care research. And that’s what I’ve helped to develop and hopefully I’ve contributed to, over those years. But, yes, mine’s a slightly different academic career than most clinical academics. I’ve developed skills about management, about leadership, in terms of research delivery, particularly. And it’s been a pleasure to see practices and colleagues locally develop research skills, but also skill up their practices to deliver research. When I first started, we used to visit practices. We used to try and share the vision of doing research, which we’ve done in our (St Leonard’s) Practice as you know, but not always that model. Doing research with colleagues, university colleagues or NHS colleagues. Just skilling up practices to do that, has been one of the great motivators for me over the years. We’ve moved from research as a hobby to the more skilled up research we’ve got now. And we’re fortunate enough in the UK to now have the NIHR, the National Institute of Health and Social Care Research funding – in my case, the Research Delivery Network. But I’ve moved through various local networks to bigger networks, and then more recently to national networks and delivering what started as ‘bottom up’ networks. We tend to talk about ‘bottom up’ networks and ‘top down’ networks. So I’ve gone from ‘bottom up’ networks locally when we’ve been working with GPs and their teams, to start them off on the research pathway and offer them opportunities to get research qualifications. It’s great to see some of those people still doing research now to skill up their practices, to a ‘top down’ model of actually giving significant funding to GP practices, in our case across England, to deliver studies. So, it’s been a quite a career actually, in terms of looking back over it and to be where we are today, it’s great.
“… I’ve experienced continuity, the benefits of working for 30 years in a practice that values continuity, working with patients who value continuity, and doctors who value continuity.”
Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care
and mortality.BMJOpen
Continuity of care strikes a chord with the media
EC: You were a GP partner at St Leonard’s practice for 30 years or so. How do you think the partnership model has changed? What does it mean to you, and what observations do you have about how this has changed over time? And, what are the implications for the future, as doctors seem less likely to want to be partners in general practice nowadays?
PE: I’m an advocate for the partnership model, I always have been. From personal experience, the ability to dictate the way you deliver care to your population, was one of the key highlights of looking back when I was a partner for those 30 years. It brings with it some financial issues, but also managerial issues and employment issues, and all the other things that go with being a partner. But I think collectively, if you like being the ‘master of your own destiny’ in terms of research, but also general practice provision and the ability to innovate rapidly, I think partnership is great. So, with the partnership model, working together collaboratively, I can see why younger doctors particularly find partnership a challenging experience. But again, with the support from colleagues, I very much enjoyed being a partner. I was a senior partner for almost 20 years in the practice and we pivoted the practice to do things that we felt collectively we should do in terms of improving continuity or delivering healthcare in a way that perhaps other practices weren’t doing. So, it gives you that ability to innovate. Of course, it’s a highly economically efficient model as well. You probably work harder as a partner than you do when you’re salaried, but I think that is being challenged. As part of that older generation, we had to buy into practices etc. That is a financial challenge, depending on where you are in your career and your family life and things. I’m a proponent of the partnership model, but it is being challenged.
EC: Of course we can’t talk about St Leonard’s practice without talking about continuity. Perhaps we might start with your perspective, are you optimistic or a bit disheartened about continuity in general practice and where it might be in ten years’ time?
PE: The practice is renowned for its continuity work, as you say, and that’s particularly pleasing for me and for Sir Denis Pereira Gray, whom as you know, I work very closely with. So yes, I’ve experienced continuity, the benefits of working for 30 years in a practice that values continuity, working with patients who value continuity, and doctors who value continuity. I’m increasingly now talking about the benefits of continuity to the health service at large, in an environment where, as you know, continuity is dropping. In particular, we talk about relational continuity; the relationship, typically with the GP, which I value; delivering health but developing that knowledge around patients and their families. I still get stopped in the street or at football matches by various people who used to be my patients, and they love to tell me their stories. And if you like stories, you learn so much about patients, but they also learn about you and that connection. I think there is a hesitation around that nowadays in terms of professional boundaries, but that wasn’t an issue for me. And I think, having experienced working in the practice and actually the efficiencies of working in a practice that values continuity, particularly when I was doing a portfolio career, and not seeing as many patients as others, but still these were patients I knew well. I knew their family. I knew their background. We didn’t have to start from scratch every time. The benefits of relational continuity that I experienced, they are being challenged, and it’s one of our missions at the moment to try to restate the benefits of relational continuity, particularly with GPs, and to generate evidence around relational continuity with other professionals, which is lacking. And then, to put that out there to policy makers and decision makers in the health service. I think the UK is probably behind other countries in this, which I think is a reflection of our reduced workforce. We need more GPs, but I think we need to be espousing the benefits of relational continuity as we are doing, and trying to incentivise it, trying to restructure practices, if the partners are willing, to deliver that. I have this ‘black swan’ analogy, if you read Nassem Nicholas Taleb’s book, ‘The Black Swan’: if you’ve never seen a black swan, you don’t know they exist. It’s very similar with continuity, I think. If you’ve not worked in an environment where continuity is valued, where patients value it and the doctors value it, and the whole practice runs in that way, whether it’s personal lists, or in another way, then I think you don’t realise the benefits. It’s almost like a sort of parallel universe – if you don’t see the benefits, you don’t realise. We know though, from when we’re talking to other colleagues now who are still practising, it can be done. It can be done with part-time GPs, as we did it. It can be done in areas of social deprivation; there are many good examples across the country. But, it’s being challenged, and what we need is a policy push to promote relational continuity and incentivisation.
EC: Professor Phil Evans – thank you so much for your time and for providing us with a window into your wealth of experience and your unique perspectives. I wish you all the best in your ongoing endeavours.
