The prevailing narrative about general practice is of an out-of-date cottage industry which needs to be pulled into the 21st century, with its model of repeated face-to-face consultation fundamentally reformed. New models are emerging that split out different services for different groups of patients: easy access schemes like walk-in centres for those who prioritise speed and convenience, and more intensive care for frail patients with many illnesses and complicated needs.
This report asks what might be lost as doctors and patients are reallocated to these services, especially those focused on easy access. The traditional model of general practice, sometimes called 'medical generalism', involves GPs developing a relationship with a patient, and understanding their social and family background. It can make them more able to decide when medical treatment is not helpful or necessary, and to manage patients safely outside hospital. Are we at risk of losing the value this delivers to patients and the wider NHS?
It concludes by looking at what GPs and national NHS bodies can do to get the best of both worlds.
- Policies designed to segment general practice often emphasise faster access to quick, transactional, 'see and treat' encounters. The rapid growth of these services is pulling GPs away from the expert ‘medical generalist’ role of general practice that is a defining characteristic of list-based primary care.
- Medical generalism involves using deep contextual knowledge of patients and their family and social situation to understand and interpret symptoms and problems. It enables GPs to hold clinical risk in the community without onward referral to other services. For around a quarter of patients, it can help to ‘de-medicalise’ problems for which medicine may be unable
to find an answer.
- Health systems like the NHS, which feature strong primary care with GP-registered lists and a gatekeeper function, generally have better health outcomes at lower cost. Evidence suggests that GPs contribute to this by requesting fewer tests and procedures and, where there is continuity with a lead GP, they refer to hospitals less. These approaches are characteristic of the medical generalist role.
- At a time when staff and money are in short supply, it is essential to clarify what we want from general practice and the role we want it to play in the wider NHS. There are opportunity costs associated with the current emphasis on timely and convenient access because fewer resources are left to deliver medical generalist and multi-disciplinary care.
- Focusing too much attention on using technology to improve access may exacerbate supply-induced demand and distract us from thinking more broadly about where technology adds value (for example in long-term conditions surveillance or risk factor monitoring) and where it adds extra layers of work with limited benefit to patients.
- It is important to distinguish patients who will achieve good outcomes from the transactional encounters of access services from those who will benefit from medical generalist or multi-disciplinary care and research is needed to work out how to do this. Software that analyses clinical data and patterns of service use can help to identify who falls into which category
in order to steer them to the type of clinical encounter that will deliver the greatest overall value.
- Traditional general practice has not always delivered good medical generalist care, especially with growing numbers of part-time doctors. Working with nurses and other professionals to provide ‘team-based continuity’ could provide an answer, and medical training should change to teach aspiring GPs how to do this.
- Comparisons are needed of the overall outcomes and costs of care for specific conditions for people treated in different forms of segmented primary care.
- Future models of general practice should aim to offer enhanced access and medical generalist care, within a single integrated organisation and supported by systems to steer patients seamlessly between different forms of clinical encounter according to need.
Rosen R (2018) Divided we fall: getting the best out of general practice. Research report, Nuffield Trust