General Practice: Jack of all trades and master of one

The NHS media profile is dominated by hospital crises, with the rock of growing demand (based on increasing need and rising expectations) meeting the hard place of static resources.

In this ‘perfect storm’, the whole welfare state colludes in damage limitation: Social Service departments expediting the transfer of hospital patients into care homes, and GPs helping deal with patients before and after admission.

There are several dissonances here: facilitating access to hospital services jars with a ‘primary care led NHS’[1]; the episodic treatment of malfunctioning body parts isn’t ‘people based;’ and the focus on institutional services is hardly ‘care closer to home’[2].

So it seems appropriate to revisit some of these concepts and see whether and how they fit into a modern healthcare system.

At the NHS front end sits primary care, based on general practice. GPs were central to the creation of the NHS: generalists running their own (for profit) businesses, often singlehandedly. They treated whom they could and referred those they couldn’t to specialists, a balance depending on individuals’ skills and interests.

Over time, circumstances and legislation have produced larger practices, becoming more systematized and providing ever more services ‘in house’. These changes have focused largely on treating diagnoses, with less attention on looking after people who happen to be ill. The triple diagnosis[3] (the physical, psychological, and social aspects of any illness) is a key attribute of holistic care, that acknowledges that sickness is determined by more than physical symptoms: dis-ease does not equate to disease. Without acknowledging the difference, healthcare systems are doomed to treating the symptoms of ever more people without addressing their broader underlying causes.

Barbara Starfield was an eminent American researcher who understood this distinction. She researched the impact of primary care on population health in many OECD countries [4]. Firstly, she described the roles of general practice, demonstrating several unique attributes in its most effective configurations:

  • first point of access to care (hence ‘primary’ care)
  • offering comprehensive services (defined by patients’ notions of illness, not clinicians’)
  • using referrals to control access to institutional care
  • coordinating patients’ journeys, wherever in the system they find themselves

Secondly, she showed a direct correlation between primary care maturity and overall healthcare efficiency. For instance, the UK and Scandinavia have deeply embedded general practice systems, and highly cost-effective health services; the USA, in contrast, has poorly developed family practice, and the world’s most expensive healthcare, whose impact on health is disproportionately poor.

However, the current UK zeitgeist is rapidly undermining all these precepts:

  • initial access to services in acute illness increasingly seems to be through A&E departments rather than primary care
  • that care focuses on physical diagnoses, a reductive definition of ‘comprehensive services’
  • the control of spending associated with holistic approaches to care is being subsumed in the drive for measurable ‘KPIs’
  • there is little coordination of care, even within the acute sector itself, let alone across the whole health and social care system

In Starfield’s typology, the NHS is losing its inherent advantages and becoming more expensive and less effective. Could this be reversed?

The short answer is ‘yes’, but concerted efforts are required in areas including policy, resources and determination. There need to be changes to hospital services and to public attitudes, spearheaded by a significant reinvention of general practice.

In a society that values medical specialization above everything else, GPs are seen as ‘jacks of all trades and masters of none’, and are gradually evolving into ‘consultants-lite,’ increasing their technical skills and reducing their emphasis on holistic care. Policy initiatives focus largely on new technology, often in the form of tablets (pharmaceutical or electronic), and the inexorable pressure to treat symptoms rather than people becomes ever more deeply embedded.

In reality, to achieve the kind of integration described by Starfield, general practice does require Specialists, but ones who specialise in the complex field of Generalism, that vague concept that encompasses empathy, psychology, pattern recognition, synthesis, and the ability to manage both people and risk, as well as excellent clinical and organisational skills. If we really want ‘joined up’ care, then GPs need to reclaim their position as the conductors of the health care orchestra; their training will need to acknowledge and include all these skills (despite the difficulties in quantifying them), and society at large will need to rethink its attitudes to these ‘soft’ skills, and celebrate them.

For if managing heart failure is complicated, then case management and whole system co-ordination are truly complex, an order of magnitude more difficult to carry out effectively. General practice at scale has the potential to offer a genuine paradigm shift, but any mooted ‘super practices’ must be based on holistic, coordinated care if they are to succeed; ersatz out-patients clinics are the last thing we need.

[1] Department of Health (1994) Developing NHS purchasing and GP fundholding: towards a primary care-led NHS. London: DH (EL(94)79)

[2] Department of Health (2007) Shifting care closer to home; London: DH

[3] Marinker M (1981) Whole person medicine in Teaching general practice (Cormack J, Marinker M. Morrell D eds); London Kluwer Medical

[4] Starfield B, Shi L, Macinko J (2005) Contribution of primary care to health systems and health; Milbank Quarterly; 83(3): 457-502