A world without general practice

The views from consulting rooms in the UK and Australia are very similar. General practice is in crisis. Grossly underfunded, stretched a long way beyond capacity, patient care becoming more complex, patients finding it harder to see a GP, morale collapsing, and, with it, the collapse of a future GP workforce. Policy is made for short-term solutions without understanding the fundamental role of GPs.

What’s at stake here? Is it possible that we could lose general practice, either in the UK or in Australia? What would it look like if we did?

Many of the solutions proposed in Australia are based on asking other health professionals to do the job of a GP — pharmacists and nurses mostly. While I wouldn’t mind this sort of task substitution in a well-integrated team, multidisciplinary team care in Australia is based mostly on individual goodwill rather than systemic integration. The plans on offer seem to be based on the reasoning that GPs are expensive, but what they seem to do — write referral letters, certificates, and prescriptions — is dead simple.

For policymakers in Australia and the UK, emergency department waiting times and elective surgery lists blowing out, and patient complaints about access are the visible problems that need solving. The solution to this in Australia has been to set up some ‘urgent care centres’ — essentially expensive GP practices specifically designed not to do the whole range of general practice that might actually keep people out of hospital.

This view of health services is completely transactional. GPs should just do the things that are recommended in the guidelines. Patients, even while being ‘empowered’ and involved in ‘shared decision making’ are passive recipients of what “The Evidence” says.

A relationship is the sort of idea that appears on the whiteboard of a management consultant so it can be ignored, rather than being something that is intentionally pursued and strengthened through skills developed in decades of teaching and research in our discipline.

This is what gets lost if GPs aren’t part of a future health system. All the activities visible on the surface — management of serious illness, smoking cessation, blood pressure measurement, vaccination, everything — happen in the context of a relationship. It’s the relationship that allows us to handle the complexity of multimorbidity safely. It’s the relationship that results in the paradox of primary care — that non-GP specialists follow guidelines in their specialty more closely than GPs do, but that GPs get better outcomes.

I’m not claiming that all GPs do this well, but I am claiming that without GPs we systemically remove the part of the health system that has researched and trained in handling relationships and complexity, and is capable of doing this well.

Without GPs, the health system will manage transactions adequately. Health services will apply protocols quite well, and manage the average patient reasonably well. There are very few average patients, though. Outcomes will worsen as care can’t be tailored to individuals. Patient experiences worsen as the therapeutic relationship is no longer combined with expert generalism. Undifferentiated symptoms get referred on more frequently, or are over-investigated. People get passed between multiple members of a multidisciplinary team, with no one taking an overview or overall responsibility.

Often, if we want to imagine a world without GPs, we just point to the health system in the US, but this doesn’t describe what we’ll actually lose, as no one’s realised yet the messy complexity that GPs deal with every day, and the pragmatism that protects patients from the worst of the health system, and protects the rest of the health system from problems it can’t manage.

We need to be able to describe what health systems stand to lose before we are reorganised into oblivion.

• © British Journal of General Practice 2023