The nature of general practice
BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7029.456 (Published 24 February 1996) Cite this as: BMJ 1996;312:456
- Per Fugelli,
- Iona Heath
- Professor of social medicine Institute for Social Medicine, University of Oslo, Box 1130, Blindern, N-0318 Oslo, Norway
- General practitioner Caversham Group Practice, Kentish Town Health Centre, London NW5 2AJ
Yes to traditional values must mean no to fundholding and managerial ambitions
Patients and doctors are actors in a play written by history, directed by culture, and produced by politics. Over recent years, the producer has become increasingly autocratic, ignoring the experience of the writer, the sensitivity of the director, and the expertise of the actors. This has happened in many countries1 but perhaps most obviously in the setting of British general practice.2 The almost simultaneous introduction of a market ideology into the NHS and the imposition in 1990 of the new contract for general practice have been experienced as threats to the very nature of the discipline.3 4 General practitioners have felt bewildered and undervalued and there has been a worrying fall in applications for both vocational training schemes and practice vacancies. Government, policy makers, and managers are perceived as valuing the internationally recognised cost effectiveness of British general practice without understanding the nature of the subtle transactions between doctor and patient which make that cost effectiveness possible. General practitioners are asked to take on more and more and they sense that the real substance of their work is being marginalised.5
Such upheaval is profoundly threatening, but it has also forced general practitioners to reflect on their predicament and to seek to define the essential content of their discipline in the context of modern primary care. The Royal College of General Practitioners has made a major contribution to this process with the recent publication of its report on the nature of general practice.6 Traditionally, general practice has been committed to the needs of the individual person, public health to the needs of populations, and primary care to the needs of both.2 The college's report dissects the processes by which, when general practitioners abandon their commitment to the individual patient and move into the wider arenas of primary care and public health, a number of practical incompatibilities, ethical conflicts, and professional tensions ensue.
The report describes the way in which the multidisciplinary team has become the unit of modern primary care, extending the range of general practice to include disease prevention and health promotion; but teamwork, skill mix, and delegation erode personal doctoring and continuity of care, both of which are valued by patients. Gatekeeping has always been an essential task of general practice; general practitioners deal with 90% of the health problems presented to them7 and act as an advocate for those patients who require specialist services. In the new market driven health service the rationale of gatekeeping has shifted from the best interest of the individual patient to a utilitarian population perspective. The role of financial gatekeeper, with its emphasis on cost containment, endangers the basic trust patients need to have in their doctors. A more managerial role gives the general practitioner administrative power but dilutes the doctor-patient relationship. Paperwork grows; patient work shrinks. Lack of time leads to fragmented care and limits clinical standards. The report concludes that tighter contractual and bureaucratic control undermines the capacity of general practice to respond flexibly and sensitively to the different needs of each patient.
Courageous choices must be made
Confronting these conflicts, the college restates two enduring strengths of general practice. The first is the continuous longitudinal relationship with patients which produces the personal knowledge and the mutual confidence that enable the general practitioner to match appropriate services to the particular needs of the individual patient. The second is the particular expertise of the general practitioner, whose clinical skills are adapted to the undifferentiated nature of the problems presented in primary care, the clinical probabilities and dangers that arise, the low technology setting, and the potential for using time as a diagnostic tool.
The college's diagnosis of the current trouble and its description of the eternal nature of general practice are both well done. However, although the report asks the right questions, it seems to lack the courage to find the answers and define the way forward. The last chapter describes the results of a laudably wide consultation exercise driven by an awareness that many of the questions must be debated well beyond the confines of general practice if enduring answers are to be found. This leaves a troubling sense of trying to please everyone. Choices must be made. Affirmation of the traditional model of general practice demands the rejection of those changes which threaten it. Yes to availability, continuity, and advocacy for the individual must mean no to fund holding and managerial ambitions.
In a fractured and distressed society,8 general practice has undeniable strengths.9 Accessible to all and free at the time of need, general practice promotes equity and solidarity. It offers value for money and inhibits the inappropriate and expensive use of specialists.10 General practice remains dependent on the human touch and counteracts the reliance on technology and fragmented specialist care which can sometimes result in a lack of compassion. The increasing availability of knowledge through information technology is challenging traditional medical paternalism. General practice is pioneering the shift from an authoritarian to a democratic model with doctor and patient as coproducers of health.7 Modern fragmented technomedicine induces unrealistic and dangerous expectations while at the same time promoting dependency. Biological variation and the stresses and misery of human life are converted into diagnoses with consequent demands for specialised investigation and treatment.11 The general practitioner can counteract both the somatisation of unhappiness12 and help increasingly sophisticated consumers to recognise that the achievements of medical science remain limited. Unfortunately the profession is also fractured and distressed, and this may explain why, despite all this, the college stops short of making a final judgment. Times of turmoil are times of opportunity but not if tough decisions are indefinitely postponed.