General practice has been described as the ‘jewel in the crown of the NHS’. But it’s not always clear that we know what it is there for.
Reports about the future of general practice tend to include a long list of things that it should be doing. It’s no longer about just being the first point of contact for health problems, prevention and early diagnosis: GPs are also to provide specialist services and help run accountable care systems.
At the heart of current uncertainty about the role of general practice lies a tension. With general practitioners a very scarce resource, how do we balance a highly accessible but transactional form of general practice – offering rapid assessment and treatment for specific symptoms – with a relational approach, rooted in local communities and in ‘medical generalism’?
Medical generalism requires a continuity of relationship between GPs and patients, and a deep knowledge of a person and their family and social context. It enables GPs to decide – after first undertaking suitable investigations – that they can help a patient without onward referral to specialists, or to avoid trying to provide a medical response for symptoms where medicine has no answer. Evidence suggests that this is why health systems with list-based general practice can achieve better outcomes at lower cost.
Access, frustration and segmentation
Frustration about long waits for GP appointments has triggered a line of thinking that general practice should be ‘segmented’. Rapid access clinics should deal with short-term illness, leaving traditional, continuous general practice to focus on people with long-term conditions, terminal illnesses, ongoing mental health problems and more.
A plethora of ‘segmented’ services have emerged. At the rapid access end we have private video consultations, walk-in clinics, treatment centres, minor illness services and urgent care centres. At the other end of the spectrum, ‘Health 1000’ in North East London and various vanguard ‘care home practices’ focus on complexity and care coordination.
In a new Nuffield Trust report, Divided we fall: getting the best out of general practice, I argue that these initiatives risk making it hard to deliver medical generalist care across the whole population and jeopardise the value general practice delivers to patients and to the NHS as a whole.
The report highlights three problems with the idea that populations can be split into discrete segments with different types of need.
Why separate services don’t always work
First: people move between segments – or they may belong to two or three segments at once. Somebody in the “mainly healthy adult” segment may develop abdominal pain or pelvic pain that needs several consultations to reach a diagnosis. A diabetic patient leading a full, active life may suffer a broken ankle and then become depressed. They then risk spinning around fragmented access services – when what they now need is not faster diagnosis of a straightforward problem, but a clinician to assume overall professional responsibility for their care.
Second, it can be harder to resist ‘over-medicalising’ care for symptoms that could be managed without medication or onward referral if the GP doesn’t know the patient.
Third, we don’t have enough research yet to really know which types of patients achieve good outcomes through transactional encounters, and which will do better at lower cost with the continuity and depth of relationship of medical generalist care.
An alternative vision for the future of general practice
How can we get the best of both worlds? We suggest ways to strike a virtuous balance between convenience, good clinical outcomes, cost effectiveness and equity.
The report doesn’t advocate any particular organisational form – emerging models like primary care homes and local care networks could all work. What is important is that they preserve a holistic, yet accessible, general practice. Rapid access for some individuals should not be at the cost of disrupted services for the remainder of the population.
Technology and data are the integrating factors that can join up these goals. Learning from leading integrated care organisations, sophisticated analysis of data from all parts of the NHS can be used to identify which patients can have their needs met in transactional services and which need proactive interventions or continuity.
More can also be done to harness new technology: using it to transform care and increase value rather than simply mimic a 24-hour supermarket. Technology can help monitor long-term conditions, bring artificial intelligence to bear suggesting possible diagnoses, and enable patients to access and manage information about their health. But caution is needed. While some studies describe benefits in terms of costs and outcomes, others find duplicated contacts and increased workload.
Getting the balance right
With a shrinking workforce and too little money, available resources need to be organised equitably to address needs across the whole population. There have been several recent Twitter spats between fans of the instant access provided by GP at Hand and GPs (accused of being protectionist) who voice concerns about its impact on GP services for the wider population. These illustrate the divisions that can emerge when competing priorities are left to collide on the front line.
We need to be clear that easy access and more complex management both have their place, so that we can focus on getting the most value from old and new ways of working. Finding the right balance between personal continuity, rapid access and thoughtful use of technology that preserves that value of general practice will be hard to achieve – but worth the effort.
Rosen R (2018) "Finding the right balance: how to get the best out of general practice", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/finding-the-right-balance-how-to-get-the-best-out-of-general-practice