The central importance of the personal primary care physician is one of the messages in Larry Green's editorial1 on the healthcare reforms which are planned and needed in the UK and the US. Even before the financial winter, the shift of the focus of care of many patients from the secondary (hospital) sector to the primary (general practice and family medicine) sector had been recognised as holding the key to affordable and comprehensive medicine. The planned reconfigurations of hospital services and the amplification of the secondary–primary shift make it more important than ever for primary care physicians and their teams to be adequately equipped for the job. And the job is changing. Management of the major non-communicable diseases is becoming increasingly complex and challenging, each year seems to bring a new threat from a new infectious disease and the changing demography and expectations of our patients have new implications for medical practice. Some of these challenges are well illustrated by the papers in this month's Journal.
The studies on sleep problems — insomnia and sleep apnoea2–4 — draw attention to a neglected and under-researched area of primary care practice, and remind us of the significance of sleep disturbances in patient's lives. The identification of sleep apnoea and the management of sleeplessness are not straightforward and are probably topics for which recently-trained GPs are likely to feel ill-equipped. Dealing with HIV-positive patients in general practice and the incorporation of an informed approach to the acquisition and interpretation of genetic information are two further topics which also highlight problems for primary care clinicians.5 None of these subjects are likely to have been routinely covered in the undergraduate curriculum and may well not have been dealt with in-depth during postgraduate training.
Just as the research required to inform effective, evidence-based primary care practice cannot simply be transferred from secondary care settings to primary care, so education for practice needs to be provided in the right context. The increasing complexities of chronic disease management require increasingly sophisticated training. The recent decision by Medical Education England not to approve an extended training programme for general practice is a considerable disappointment and seriously threatens the capabilities of the next generation of GPs to take on the new responsibilities that health service reform will undoubtedly imply. An extended, flexible curriculum, offering additional specialist internal medicine experience and more time in practice, learning to cope with ‘the new primary care,’ is essential if general practice is to meet the expectations that will inevitably be placed upon it. The current 3-year programme — with 2 years in hospital and one in practice — is out of step with many western European countries, looks decidedly thin compared with specialist training in other disciplines, and is an unsatisfactory platform for the career development of the next cadre of academic GPs required to lead teaching and research in the future. Extended vocational training could, for example, include Masters level study for graduates wishing to prepare for academic training fellowships and educational careers for those wishing to take their skills in clinical medicine and health services management to higher levels — the foundations for a meaningful career structure for general practice.
By the time the next issue of the BJGP is published we will know who is governing the UK. Some of the main parties' proposals for the future of the NHS appear to represent sensible ideas for progress.6 Yet some have already met with resistance from clinicians and managers who wish to cling to an unsatisfactory status quo. While re-organisation fatigue is a well accepted side-effect of health service reform, it now seems impossible for us to stand still and survive. Many of the longstanding pathologies of our system, perhaps most damagingly, the deep divide between primary and secondary care, and the failure to work creatively and efficiently together, require urgent attention. Leadership, goodwill, and flexibility are required of us all.
- © British Journal of General Practice, 2010.