Abstract
The current state of general practice in the UK is worrying. You don’t have to be a health services expert to have picked this up. Anyone who has opened a newspaper or switched on a television or radio news broadcast in the past year or two will have read or heard about the serious challenges that are being faced by general practitioners (GPs) across the country.
For some years, there has been talk about underfunding, increasing workload and grave recruitment problems. At the Royal College of General Practitioners annual conference in October 2014, the college chair, Maureen Baker, used a fitting metaphor that likened general practice to a dam that was at bursting point. It seems that we’re on the brink of a real crisis, and in times of crisis we need to consider radical solutions.
The problems come down to some simple mathematics. GP workload is being increased by reduction in allied community healthcare workers, increasing patient demand and the increasing complexity of medical and social presentations. Despite the increasing burden of work, the amount of money coming to general practice, as a proportion of National Health Service spending, is falling. 1
There is a similar mismatch when considering the GP workforce. Increasing numbers of UK GPs are choosing to move abroad, work part-time or take early retirement. However, the recruitment to specialty training is decreasing, with fewer doctors considering it an appealing and sustainable career choice. 2
So where will this radical solution come from? Karl Marx defined radical solutions as those that ‘grasp the root of the matter.’ 3 Much of the debate about how to radicalise general practice has focused on the role of the independent practitioner status and whether or not GPs should be working as salaried employees of the National Health Service. While these structural issues are undoubtedly important, I propose an even more radical approach. Rather than the system in which GPs operate, the real root of their work is clinical activity and therefore, this may be what needs to be reconsidered.
The challenge is to attract more doctors to consider GP training, attract more funding to primary care and renegotiate relationships with patients and hospitals. In order to do this, one must carefully consider the changing role of the GP. The discipline has evolved hugely over the years and many chronic diseases are now managed in the community, with growing pressure to minimise referrals to secondary care.
This model is clearly beneficial both in personal terms to the patient and in financial terms to the National Health Service and is a real strength of the British healthcare system. However, when you look at the Royal College of General Practitioners curriculum and consider the breadth and depth of skills needed across different clinical areas, 4 it becomes apparent that the role is dramatically different to what it was a generation ago. The idea that a doctor can gain all of these skills in a three-year training programme is absurd and the proposed extra year of training on the horizon seems unlikely to be enough.
Improved treatments and increased life expectancy mean we have more older people and more multimorbidity. This means an increasing amount of GP work is highly complex and involves working outside of current single disease national guidance. This requires a level of expertise at least as much as hospital consultants, whose training is twice as long and often more.
Importantly, not all GPs value this aspect of clinical work equally. Doctors choose to come to the specialty for a variety of different reasons. Many prefer the variety of dealing with acute problems and are happier tackling infections, rashes and muscular strains than getting deeply immersed in complex pharmacology and negotiating the uncertainty of working outside of clinical guidance. An increasing number of GPs are opting for portfolio careers and sessional employment, where clinical work may be a small proportion of the working week. These professional considerations are also affecting the extent to which GPs want to engage in different clinical activities.
One way to solve this may be to redefine the role of GPs and create two subspecialties. The first group, who may be branded as ‘community health consultants’, would be expert clinical generalists whose training would include aspects similar to that of internal medicine physicians. They would focus on multimorbidity, complex chronic disease management and shared decision-making in preventive care. They would take on a proportion of the care currently being undertaken in hospital outpatient clinics and their appointments would be longer than the traditional 10 minute slots and largely be pre-booked rather than ‘on the day’.
The second group, who may be branded as ‘acute community consultants’, would include a training path way which shared common themes with emergency medicine doctors and whose work would focus on self-limiting illnesses, acute infections and minor injuries. They would operate an ‘on the day’ booking system, relieve pressure from emergency departments and have the ability to easily pass medically complex cases onto their community health colleagues (who would work in the same centre) when clinically suitable to do so.
General practice needs a shake-up. It needs to be more attractive to doctors and needs to renegotiate its role within the health system. In these financially difficult times, there may be room for primary care to actually expand and take on work it can do more efficiently than hospitals. In addition, the long-running tension about managing access and continuity in primary care could also finally be tackled.
Many GPs enjoy the ‘counselling’ aspects of their work and relish opportunities to guide individuals about chronic disease management, preventive care and psychosocial wellbeing. Others, meanwhile, value the ‘firefighting’ aspect of their work and enjoy being able to tackle more acute problems. Perhaps if these new roles were clearly defined and branded into distinct but related specialties in the community, the current crisis could be used as an opportunity to reinvigorate the specialty and make it fit for future challenges.