Deconstructing the Doctor

The past President of the British Medical Association, Professor Pali Hungin, was so concerned about the future of medicine and the future role of the doctor, that he held an international colloquium on the subject. Key questions included whether medicine, and by implication, medical training, is able to keep pace with the technological, professional, and societal changes affecting medical practice. What will doctors be doing in 20 or 30 years’ time? How can we prepare for an unpredictable future? Similar questions must have been in the mind of the new President of the Royal Society of Medicine, where a public debate on the past, present, and future of the NHS took place in mid-August, with Stephen Hawking as a keynote speaker. Traditional medical roles and functions have never been under greater scrutiny.

When Professor Martin Roland was commissioned by Health Education England to report on the workforce requirements of an effective future primary care system, his recommendations included a strong emphasis on teamwork and the incorporation of new professional roles into general practice and primary care.¹ The report was cautious about the strength of the evidence for some of these new professional roles, and perhaps a little optimistic about the readiness with which they are likely to be systematically assimilated into existing structures, relying on ‘well-motivated professionals’. In this issue of the BJGP we have published two articles and an editorial about the potential role of pharmacists in general practice, which illustrate more general points about being receptive to and maximising the impact of new members of the primary care team; there has to be clarity, as well as professional and public agreement and understanding, about exactly how they will work together. As Professor Tony Avery’s editorial points out, the funding formula also needs to be right for these initiatives to succeed. The same probably goes for a number of other potential members of the primary care team, including physician associates, psychologists and extended role nurses. And, of course, Roland’s team is right in stressing the need to make sure that these novel roles represent good value for money; there are many examples of alternatives to traditional first-contact GP consultations that have turned out to be more expensive.

This raises a much bigger question, which is whether what we believe about the clinical and cost effectiveness of general practice, derived from some quite old studies from Barbara Starfield and others,² will apply to new primary care structures? Now and in the future, patients may have first contact consultations, as well as receiving continuing care for chronic diseases, with many other members of the team. The Starfield research was conducted when the gatekeeper role was taken by GPs with a wide repertoire of skills and experience, and with extensive knowledge of their patients and their life situations. Can this be replicated by a group of non-GP professionals each doing a part of the ‘traditional’ GP job? In other words, is a well-trained, experienced GP or primary care clinician more than the sum of their parts, or not? Is it really possible to pick off segments of the job — chronic disease management, scrutiny of laboratory and imaging results, telephone triage, counselling, perinatal care, minor surgery, complex medicines review, emergency care — for others to do? And leave what? Answers, please, on a postcard.

In Life&Times we report on a celebration of the world’s very first Professor of General Practice, Richard Scott, with an eponymous lecture, a blue plaque and, quite possibly, a dram or two. With Edinburgh leading the way, 54 years on every medical school in the UK has something approximating to a Department and Professor of General Practice, although sadly many of these departments are being subsumed into almost meaninglessly-titled groupings such as Population Health or Community Health Sciences. Little surprise that medical students don’t think of general practice as a career choice, when they can’t even see it at medical school.

• © British Journal of General Practice 2017