This issue of the Back Pages has usefully brought together two challenging views of the future. One is predicated upon delegation of the more mundane duties of present-day GPs, and the other contemplates enhanced clinical responsibility filtering down from the ‘clever doctors’ who presently inhabit the secondary sector of health care.
Woodroffe is impressed by the skills and application of nurses, pharmacists and others in their handling of chronic illness, pointing to better health outcomes, patient satisfaction, more choice and longer consultations, leaving the GP in the background as a back-stop for the difficult case with multiple or poorly-differentiated medical problems.1 And she is probably correct, indeed, such thinking is the engine for the current enthusiasm for nurse consultants and physician assistants.
So what might militate against this development? Three factors come instantly to mind; shortage of personnel, a standard 37-hour working week and an attrition of the very clinical skills nurses would expect from their GP colleagues in support of their own.
It is well recognised that doctors are in short supply, but so are nurses, a fact amply demonstrated by the mass defection of experienced nurses to the green fields of NHS Direct and NHS24 — until they ran out of money. Our nursing colleagues work hard, but only for 37 hours a week and many naturally put young families at the forefront of their concern, not necessarily their employing practice. Most GPs know, especially as they grow older, that if they are not employing their skills regularly, even in routine, humdrum situations, they tend to diminish exponentially.
Hodgkin's vision, however, is far more radical than mere delegation — he advocates a new, complex, capital-intensive structure that borrows more from Kaiser Permanente or health maintenance organisations very similar to the ‘super-practices’ predicted by Donald Irvine over a decade ago.2
He sees predictive statistics being employed as a diagnostic tool; he enthusiastically embraces the confidentiality risks of Connecting for Health and sees technology leaving the strict confines of a building now quaintly termed ‘hospital’ to become, with its attendant clinical experts, a community resource with multidisciplinary teams destroying organisational barriers to the benefit of patients. His vision is one far removed from my personal experience of a small, rural practice and the way of life I chose over 30 years ago.
These two thoughtful and well-written articles deserve to be read, digested and to inform the never-ending debate on the future delivery of UK health care notwithstanding the danger that they tend to ignore the enduring values of those who practised in 1948, and well before. I would make two observations. First, doctors are eminently skilled in embracing and adapting to change, especially so in the last two decades, but their professional values are also capable of reacting to those changes to the continuing benefit of patients. Second, there has never been a generation of doctors that has not despaired of the generation that has followed it, forgetting that it is only the expression of professional values that changes, not their underlying ethos.
But, having said that, there is still lingering unease. Currently, there is tension in the land of general practice between nostalgic traditionalists holding on resolutely to familiar concepts from a simpler time before the 1990 contract — and between others who are prepared to contemplate a newer, post-NHS world.
The danger is that Woodroffe and Hodgkin, prepared to describe such a world, are considered heretics and apologists for a political initiative to privatise and submit the NHS, our great post-war social experiment, to the rigours of commercial competition, reflecting tensions that were patently obvious at the BMA's 2006 annual meeting in Belfast. While they may frighten the horses with their radical view of an uncertain future, we traditionalists try to seek reassurance in the more philosophical view that while change is inevitable, what drives us as physicians is not.
No matter our discomfort, however, we must defend to the last the right of those who propound unpopular or challenging views of the future to state them. In the final analysis it is reassuring to know that there are those within our professional community with the courage to challenge orthodoxy and complacency. Leadership, at a time of anxiety, changeexhaustion and corporate navel gazing is infinitely to be preferred to stagnation and inertia.
- © British Journal of General Practice, 2006.