Iona Heath's leading article 'The medical care practitioner: Newspeak and the duping of the public1 has real merit in its defence of the role of the well trained, experienced general medical practitioner. However, it is deficient in that it is unclear whether she is taking offence at Newspeak itself or the planned development of a new tier of clinician by the Modernisation Agency. If it is the latter then she should think again.
General practice has changed out of all recognition in the last 50 years, partly as a result of medical education and partly out of the public's increasing critical awareness and access to primary care. Marshall Marinker used to speak of the ritual, the routine and the drama of general practice. Most experienced and certainly most inner-city GPs would recognise that much (not 60%, but a lot) of the ritual and routine of surgery consultations can be screened and often handled by clinicians less qualified than highly-trained doctors. How much of our working days are repeatedly interrupted and frustrated by currently legitimate demands on us to deal with the trivial, the self-limiting and, sadly, the incompetent?
Recruitment into general practice is at a low. In part this is because some sections of everyday clinical practice are unattractive to highly-trained, bright medical graduates. If this dull, repetitive routine and ritual is at least shared by other less trained clinicians, then this will release the new generation of GPs to actively become involved in further higher professional training, including specialist medicine, education, management, medical journalism and politics.
The role of the GP needs to be underpinned by two significant principles. Referral rights should largely be confined to GPs. Younger colleagues appear too easily to concede their role to other clinicians in the name of equity and modern practice. This diminishes the role of the GP and increases health spending. Rather, non-medical clinicians should be required to refer to GPs for second opinions and advice as to how to further manage and/or investigate a problem. With time, trust will grow so that boundaries will become blurred, but the principle will remain. Secondly, patients should be able to continue to choose the type of clinician with whom they wish to consult. Here, Dr Heath's point about choice having to be informed and not misled is well made. Experience suggests that patients are very good at choosing ‘horses for courses’ once they understand what is on offer.
In these ways Iona Heath's concerns for public safety will be alleviated, the role of the GP enhanced, the health economy protected and the patients' needs met.
The agenda around physician assistants or medical care practitioners need not be resisted — it should be shaped — by us general practitioners.
- © British Journal of General Practice, 2005.
