The consultation, the central activity of general practice, is the theme of this issue of the BJGP. This brief yet potent encounter has been endlessly discussed and dissected. What goes on in it and what should go on? How can it be structured and choreographed? How long is it and how long should it be? What happens when an intruder appears — a trainee, a relative, an interpreter, a medical student? A computer? How do we make it easy for patients to get one — but not have too many? We do at least know that consultations are getting longer and more complex, reflecting the changing demography, epidemiology, and health-related behaviour of our patient populations, and their expectations of health care, as well as the pressures within the health and social care system for general practice to take on more and more work from other sectors. We also know that the doctor–patient encounter is at the core of our professional role, although we do not really know what it will look like, and what it should look like, in today’s and tomorrow’s distributed, digital worlds.
These questions about the nature of the consultation in the general practice of the future are being asked against a background of frequently reluctant uptake of innovations across the NHS, and uneven enthusiasm among GPs for creating digital alternatives to traditional ways of communicating with patients. Jon Banks and colleagues have studied the use of one of the currently available e-consultation tools in a number of practices in the West of England. They found, perhaps unsurprisingly, that they were not always easy to integrate into existing practice IT systems. Simple tasks carried out by GPs and practice staff such as repeat prescriptions, enquiries about fit notes, and test results, for example, could be carried out effectively. However, when the interactions were potentially more complex, for example, involving the appraisal of symptoms described by patients on electronic proformas, they were much less easy to complete, and frequently generated additional work, including re-consultation.
In another, quantitative, study Hajira Dambha-Miller and colleagues asked a group of longstanding type 2 patients with diabetes about the aspects of care that they most valued. Again, perhaps unsurprisingly, they rated more time, better continuity, and face-to-face contact with their doctor most highly. Ironically, of course, these are precisely the attributes of general practice that are becoming most difficult to sustain, as new professional roles are introduced to complement the struggling GP workforce and patient care is increasingly fragmented. Whether remote e-consultation with patients, using video linkage, can eventually substitute for some clinical contacts in the management of chronic disease such as diabetes is not known — but it well might.
At the start of the New Year it is natural to look ahead, and wonder what is in store. Two of our editorials do just that. John Sanfey and Sanjiv Ahluwalia argue for less control and less heavy-handed management in the NHS, replacing these constraints with openness, trust, and collaboration, along with the recognition of the critical role of clinical expertise in planning services. This aligns closely with Don Berwick’s third era of medicine, when openness, civility, and collaboration succeed the preceding eras of professional self-regulation and of performance measurement.1 Aniket Sonsale and colleagues wonder if some of the present and foreseeable changes in general practice, such as the benefits of working at scale in confederations of practices, may become more difficult to achieve because of the lack of engagement by many GPs, who seem to be opting for salaried roles, with little interest in clinical leadership. This is, of course, another argument for recognising the importance of clinical leadership in the health service, for equipping and recruiting young doctors for new roles in the future, and offering more of a career structure to established practitioners. Let’s hope that it is possible this year to grasp some of the opportunities offered by the present difficulties in the NHS, and to restore a sense of pride in what we do, and of optimism for the future. The BJGP team wishes all its readers a very happy New Year.
- © British Journal of General Practice 2018