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At the heart of general practice since 1960

Is the golden era of British general practice coming to an end?

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Looking at my work patterns over the last few years, it is becoming clear that the model of general practice as we have experienced it since the inception of the NHS is changing irreparably.

There are some commentators who believe that a GP is an obsolete role. How can one doctor know what there is to know about all the various medical subspecialties and all the diagnoses? In an era of empowerment of patients, if the patients has a heart problem for example they should be managed by a cardiologist, or if the patients has diabetes they should see a diabetologist. I can see some validity in this argument, as I cannot hope to know as much about cardiology and diabetes as the aforementioned specialists.

But over the last few years I have seen a salami-slicing of tasks that we used to be responsible for - maternity care has been taken away from general practitioners and handed to midwives, management of breast disease has been moved to breast clinics, and we now have MS nurses, Parkinson’s nurses, heart failure nurses and the rest.

Some of my patients now have a multiplicity of people providing medical attention. Advice is clearly contradictory at times and the patients face an endless streams of appointments with a series of different people whose skills vary in both quality and ability. Each one focuses on their own microcosm of activity, and rarely contributes anything of much use to the patient’s health.

Complex elderly patients now spend much of their time being ferried around from department to department, with minor changes in therapy recommended as that is what they do. Many clinicians spend time in their departments arranging investigations that have little or no value, and merely is inconvenient to patients.

Much in hospital follow-up care is ill-thought-through and can sometimes cause more problems than it is worth. Follow-up is often pointless, sometimes counter-productive. So could we GPs do it better? There’s the rub, as Hamlet said. Can a generalist look after complex cases better than a collection of specialists?

The specialists will have greater knowledge of a smaller area, and more experience in terms of caseload. They will also have specific skills (procedures, and so on) which I cannot offer. They have colleagues that can cover other areas in the patient’s care. So on the face of it, there is little role for the GP in 21st century medicine.

And yet, I see my role as changed and unchanging.

The ‘changed’ bit is medical progress is and can do. The ‘unchanging’ bit is when I sit down with my patient, take a history and do a clinical examination. That bit is just as difficult and rewarding as it always has been.

Other roles continue. The advocacy role, for instance, is important, and so is your role as co-ordinator. I will sometimes directly disagree with colleagues when managing cases - either recommending that certain procedures are, in my view, not needed or futile. That is another vital part of my job.

The modern GP is like a orchestra conductor - all the specialists have their roles but who directs it all? This is the role I feel that I play.

So yes: I believe there is still a place for us.

The Jobbing Doctor is a GP in a deprived urban area of England. You can follow him on Twitter @jobbingdoctor.

Readers' comments (8)

  • It came to an end immediately after GPs agreed to a change of contract that allowed HMG to change it at will.

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  • Good stuff. In the old days hospital care did not offer the level of service of today. GP was crucial deliverer and 'gatekeeper of care'. The era of specialism has changed that but look at US and Affordable Care Act debate. The cycle is changing - they and we cannot afford unfocussed specialist services which is not 'managed' by GPs. GP contract lost sight of that.

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  • So many of my patients refuse to go anywhere near secondary care that I am quite sure that my job is safe for the next few years.

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  • General surgeons died about a decade ago. One of my old boss was the last of the breed. Old fashioned he was, and difficult to work with at times. But when it came to complicated matters which required a bit more knowledge outside of his speciality to make sense of the management, he was second to none.

    I fear we will go down the same route. Yet when we are gone, NHS will miss us. Our clinical skills and knowledge may not be missed but the combination of our broad general understanding of medicine and our community will be missed.

    I write this having written yet another letter to the cardiologists and nephrologists to stop fighting over the furosemide and agree on a sensible dose, rather than yo-yoing my patient between heart failure and renal failure

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  • I could not agree more with all of your experiences and conclusions. We GPs are what I call the Consultants of Common Sense. I feel that many of our hospital colleagues are over- specialised and have lost the ability to look beyond their ever narrowing field of specialisation.
    I cannot count the number of elderly patients with hypotension, bradycardia and renal failure due to ' NICE guideline' treatment provides by our Heart Failure Team I've seen.
    I feel that in particular the Elderly are served poorly by the increasing fragmentation of services and unsurprisingly it is only us who see the physical and psychological fallout from this in our surgeries.
    However I cannot see the NHS being able to survive financially without General Practice, but we might struggle to attract enough young doctors into our profession giving the 'box ticking' , QOF chasing machines we have turned into since introduction of the current contract.
    Will the NHS miss GPs? Probably only once it has gone.
    Will patients miss GPs? Definitely the ones that need us most and they are the ones that keep me going (just).
    The real question in the near future might be though - ARE THERE ANY GPs LEFT.

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  • How are patients to know whether or not they need to see a surgeon, heart specialist, etc and how would they access them anyway without a GP to filter, assess and reassure? GP's are the accessible and acceptable face of the medical establishment.

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  • I dont think the role of the GP will disappear, as in dealing with what is essentially an initial assesment and a decion to treat or refer.

    I do think that how this is done will change.

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  • I agree, the patients are treated in piecemeal, not as a whole person by the specialist, and it some time many investigations are duplicated. Its only the us GP who give some care to patient as a person, not an organ.I feel general practice will stay some form or other

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