Getting Through

About 20 years ago I suggested to a very senior NHS clinician involved in the R&D programme that short-term grants should be made available to give NHS GPs protected time to prepare research grant applications. ‘If you think I’m going to pay GPs to write grants you must be joking’ he replied. When I tried to explain that GPs needed funding to enable them to pay for locum cover he said ‘Oh yes, I know. My wife is a GP and I get this every morning at breakfast’. Last weekend a London consultant told me how open warfare had broken out between the local CCG and his hospital directorate over referral criteria for outpatient appointments, against a background of a toxic hospital administrative culture and a not entirely consensual approach from some of his GP colleagues.

The theme of this July BJGP is ‘communication.’ As well as highlighting excellent editorial, research and practice material on communication in its various forms, such as eHealth applications, telephone triage, and GP referral, I also thought it was worth pointing out that, while the need to demonstrate ‘excellent communication skills’ features in practically every job description, advertisement, and assessment in medicine, we still aren’t very good at it.

The trouble started in 1948 when the NHS Act split medicine into two tribes — GPs and specialists — with different contracts, responsibilities, and rewards. This tribalism often re-emerges after medical school and by the time we are in our most active clinical years can have become hardwired and destructive. I have just been reading commentaries on the implications of the Future Hospital Commission report ¹ and the Shape of Training review ² in which whole swathes of text discuss the importance of broad-based generalist training and an appreciation of the community and population context without ever mentioning the words ‘general practice’, or acknowledging the fact that about 13% of undergraduate teaching takes place in general practice, involving 40% of all practices in the land.³ Conversely, some GP curriculum designers can be equally unwilling to acknowledge the value of skills learned in postgraduate hospital settings and the limitations of general practice as a place to teach certain key topics including, unfortunately, emergency medicine.

For years there have been rumblings about the need for some sort of NHS Academy, which could perhaps reunite these medical tribes and give them a clearer sense of shared purpose. It could also equip more senior doctors with management skills that could be deployed within better-thought-out career structures, in both primary and secondary care. There are probably other ways of looking towards genuine professional integration and the achievement of mutual respect (and we need both if we are to have an effective and affordable health service). These might include paying more attention to the selection process for medical schools, and the development of training programmes with a more even balance between the primary and secondary care specialities, leading perhaps to new kinds of posts that cross the interface between generalist and specialist medicine.

Elsewhere in the Journal you will find a perceptive essay on the progress with Obamacare, a review of an engaging TV programme about general practice in south London, a salutary analysis of the national patient survey that suggests that over 5 million A&E attendances annually may be due to patients being unable to get GP appointments, and our plans to provide a structured system of feedback to our heroic body of peer reviewers. Much to communicate!

• © British Journal of General Practice 2014