Clare Gerada and Ben Riley.
‘Primary health care offers the best way of coping with the ills of life in the 21st century: the globalisation of unhealthy lifestyles, rapid unplanned urbanisation, and the ageing of populations.’
Margaret Chan, director general, World Health Organization, 2008.1
The value of the GP has been demonstrated over many decades; research in the UK, Europe, and in the US has shown that having more GPs per head of population is associated with better health outcomes, cheaper services, and better patient experience.2 Despite this, our workforce is under growing pressure from a rising age profile and a fall in the proportion of new entrants to the profession and those returning to work.3
As a profession, general practice is under constant threat. Barely a week goes by without another report implying that GPs have failed in some way: by not diagnosing cancer early enough, not prescribing safely enough, not providing sufficient care for patients with dementia, and so forth. The number of complaints against GPs has risen, so that those against us now represent nearly half of all complaints made to the General Medical Council.4 Groups with particular interests routinely announce that GPs need more training in the areas relating to those interests, yet rarely do they acknowledge that GPs in the UK have one of the shortest specialty training periods in Europe5 — nor do they acknowledge that we deliver more care to a wider population group than primary care practitioners in comparable healthcare systems.
INVESTING IN GENERAL PRACTICE
In the future, our health service will rely heavily on a GP workforce with the capabilities and competence to deliver care closer to home and reduce the state’s reliance on hospital care. Yet GPs report that they are struggling to maintain their existing workload — they are seeing patients whose conditions are more and more complex, they are in a greater diversity of workplaces, and they often single-handedly take responsibility for patients who would have previously been managed by a host of specialists.
There is a growing body of evidence that a successful GP workforce will be mission critical to the future NHS. A recent independent report on generalism6 concluded that, if GPs did not exist now, they would have to be invented, and that investing in generalism is the best way of addressing the burgeoning health needs of our population, which is increasingly older with multimorbidities. Although some may argue about the exact percentage of health care delivered by GPs, it is safe to say that the vast majority of daily contacts in the NHS involve GPs and their teams.7
Within the turmoil of a major reorganisation of the NHS in England, and the serious financial constraints facing the NHS across the whole of the UK, GPs must take control of their professional destiny. It is time to put a halt to decades of think-tanks, focus groups, special-interest groups, or politicians directing how the GP should or should not work, with little regard to the wealth of evidence on effectiveness of primary care or the unmet needs of those within our population who are vulnerable. To take this aim forward, the College has launched a major consultation exercise called 2022 GP.8 This will examine the evidence for the efficacy of the current model of general practice (collated in a compendium of evidence9) and, ultimately, present proposals for how we, as a profession, can work differently while ensuring that we stick to our core values: delivering continuous, comprehensive, coordinated, and personalised care, targeted at those who need it most. We will retain an evidence-based approach and challenge many of the centrally driven policies that GPs have been required to adopt over the years — such as advanced access, referral management centres, and the rollout of compulsory Darzi centres in every primary care trust in England — often at the expense of de-skilling the primary care workforce or overriding local priorities.
THE FUTURE OF THE GP ROLE
Whatever the future holds, GPs must continue to provide first-contact care to a registered population, across the physical, psychological, and social domains, in the context of each patient’s environment and family. Beyond this, the GP as a provider will adapt so that, with longer training and enhanced continuing professional development (CPD) and revalidation, we will further develop our role as the NHS’ ‘expert generalists’. Some GPs will take on extended roles that will include special clinical interests (in conditions in which the skills of a generalist are required to deliver care closer to home, rather than those that hospital practitioners may wish to ‘offload’), as well as education, research and development, leadership, and other professional roles.
Given adequate time and resources, the GP of the future will be leading both the planning and delivery of integrated services,10 heading up multidisciplinary teams for the care of patients who have multimorbidities, older people who are frail, those at the end of life, and those with mental health problems. We must find a way to move outside our consulting rooms and re-engage with our local communities, helping to address some of the preventable major health problems that present too late in the surgery, as well as ensuring that services are designed to improve the quality of life for all patients.
GPs have a vital role in supporting shared decision making, including the effective use of personal health budgets and carer-involved planning. GPs have always been keen adopters of digital technology and will find ways to use this to provide patients with better access to information for self-care, improve the accuracy of diagnosis, and enhance continuity and coordination of care.
The pressures on GPs to deliver effective care are mounting, as is the ability to deliver more accessible services while preserving continuity. The crisis of demand versus capacity has not arisen overnight and cannot be solved quickly. As a profession, we must identify our own workable and sustainable solutions to address the current challenges to our profession (outlined in Box 1) and increase the capacity of our workforce, enabling us to spend longer with our patients and communities, and deliver the training and CPD we need to take on new roles and responsibilities. The College will lead the way in developing a 10-year action plan to do this, drawing on the ideas, expertise, and enthusiasm of GPs in all parts of the UK. The future of our unique and wonderful profession — and that of our patients and our health service — is something we must not leave to others to decide.
Box 1. Challenges for the general practice profession
How will we continue to deliver high-quality, accessible care?
How will we improve coordination and collaboration, and reduce fragmentation of care?
How will we ensure our workforce is able to sustain the primary-care services we deliver?
How will we address health inequalities and focus care on those who are most in need?
How will we increase use of information and technology to improve care for patients?
How will we address unacceptable variability of care?
How will we involve patients and carers more in decisions about their health?
How will we lead relevant research and development?
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2012
