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What the future has in store

A brave new world of virtual polyclinics and nurse practitioners? Or will traditional practice win the day? Nigel Praities asked GP experts to look into their crystal balls

A brave new world of virtual polyclinics and nurse practitioners? Or will traditional practice win the day? Nigel Praities asked GP experts to look into their crystal balls

Listening to the fevered discussions over Lord Darzi's review of the NHS, it is tempting to assume traditional general practice is doomed.

GPs will be frogmarched into faceless supersurgeries, employed by corporations or replaced by nurses, according to the pessimists.

So could the traditional GP providing continuity of care be a thing of the past?

The jury is still out on what general practice will look like in 10 years' time.

Although the threats to GPs are real, many general practice academics believe its strengths will survive – albeit in an altered form.

For starters, in a world where patient choice is king, it is far from clear that patients will choose access over the doctor-patient relationship.

A recent survey of 1,200 patients by the National Primary Care Research and Development Centre found they valued a familiar doctor twice as much as having flexible appointment times.

Some experts believe the need for continuity of care will only increase as the population ages and GPs manage ever more patients with multiple, complex conditions.

Professor Martin Roland, director of the National Primary Care Research and Development Centre, insists GPs' holistic approach will be crucial.

‘Increasingly people will have more than one condition. These patients need someone taking an overview of their care,' he says.

Power of PBC

Professor Chris Ham, former Department of Health policy strategist and professor of health policy and management at the University of Birmingham, also argues it is essential GPs defend their gatekeeper role.

He believes the challenge will be to use practice-based commissioning to bring care into the community and allow practices to compete with the corporate model of primary care.

‘I envisage PBC could lead to embryonic managed-care organisations within which GPs provide much more care outside hospital, work with specialists and invest, if they wish to, in polyclinic-type facilities.

‘I don't think the gatekeeper role is in question,' he adds. ‘Most patients are happy with their existing primary care.

'There doesn't seem to be a groundswell of concern from the public, so I don't think they will go to Virgin or UnitedHealth.'

Professor Steve Iliffe, professor of primary care for older people at University College London and author of The Industrialisation of General Practice, is more sceptical. He says continuity of care will be undermined as patients switch to practices with longer opening hours.

Professor Iliffe, who works as a GP in Kilburn, north London, says: ‘In terms of consumers, continuity is not important, it is access to expertise. That tension will continue to exist and GPs will have a hard time.'

Professor Iliffe says the electronic care record could preserve continuity of care without patients seeing the same doctor each time. ‘If it ever works,' he adds.

Specialise or die?

But as GPs take on increasingly specialist roles and more of traditional general practice is passed to nurses and pharmacists, is there a risk GPs will become remote from patients and deskilled?

Far from it, says Professor Iliffe. ‘If we are going to survive at all we are going to have to take on increasing specialisation, or specialists will do it for us,' he says.

Not all GPs are convinced that specialisation is the way to go.

Professor Roland, for instance, believes it may not be cost-effective or sensible. ‘GPSIs potentially cream off simple cases and hospitals are left with the more complex caseload, still doing it at tariff,' he warns.

‘In some parts of the country GPSIs are not well supported by specialists, because they feel threatened.'

The virtual polyclinic

Even greater controversy surrounds polyclinics, partly because of the way many PCTs are imposing them.

But there is support for the RCGP's ‘virtual' or ‘federated' model – where GPs remain in their surgeries but share clinical issues and services.

And Professor Roger Jones, professor of general practice at King's College London, believes even merged polyclinics will have their uses.

‘There are parts of the country where a new building will help recruitment, help patients and add to the local economy,' he says.

Professor Jones warns there will be more salaried GPs and fewer partners, but it is unlikely to be an eastern European system with ‘everyone trudging round in white coats getting thoroughly disillusioned'.

‘It is a bit disingenuous to say "Oh it is awful, we are all going to become salaried" as entrepreneurial GPs are already employing salaried GPs.

'GPs need to maintain the partnership ethos, with training, teaching and research, improve the management structure and make sure there are not lots of singlehanders. There is much to be gained.'

General practice is changing its spots, most experts agree. But it is not yet ready to evolve into a fundamentally different beast.

Professor Martin Roland: specialisation by GPs is not necessarily the way to go Professor Martin Roland

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