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Building Better campaign: What services should general practice offer?


principles Building a Better General Practice


We have completed the first part of our ‘Building a Better General Practice’ campaign, looking at the role of the GP. Today, we launch our second survey, where we ask readers to determine what services GPs should be offering, having already met with our panel of experts and grassroots GPs.

Conclusions from first survey on the role of the GP

  • With resources, GPs want to retain the clinical aspects of the role: they want to provide scheduled and unscheduled care; continuity; prevention; aspire to excellence.
  • They see their role as being heads of MDTs, not necessarily providing the care, but providing coordination.
  • They see general practice as being the right place for more services to be delivered – but not necessarily by them

(See below for full results)

At the first meeting of the panel, it was raised whether something as radical as taking paediatric or geriatric care away from general practice might be something that would benefit GPs, the health service and patients. However, our first survey revealed there is not much appetite for this among GPs, who believe that it is a positive thing to retain clinical services within general practice.

So instead of thinking about what current services GPs should remove, the panel felt the best approach would be to consider principles around what services GPs and general practice are not competent to provide, and services that GPs are too qualified to provide (but could still be delivered within general practice).

Services that general practice should provide

In an ideal world, any service that could safely and adequately be provided within general practice should be, with the money following the extra patients being cared for in general practice.  This was a theme that came through the first survey too.

This does not mean that all these services should be provided by GPs; again, GPs would be the head of the multidisciplinary team, as a de facto consultant in family medicine.

Services GPs are not competent enough to provide

Currently, there is stigma around the term ‘not competent’. But stating that GPs are ‘not competent’ to provide certain services is a message that needs to be amplified for general practice to be able to function.

But how to define what GPs are ‘not competent’ to provide? The obvious starting point is anything that specialist care is unable to treat should not circle back to general practice, as is often the case (ie, when secondary care has finished investigations and is unable to treat a patient, they send the patient back to the GP).

Another principle is that anything that GPs need further training for should not be part of general practice. This is not to say that there should not be extended training, or continued professional development – but this training should be to reinforce the GP’s skills in managing undifferentiated illness.

In general, however, GPs should not be providing any care that is more specialist than managing undifferentiated illness.

Services that GPs are too qualified to provide

Equally, GPs should not be doing work that could be provided by other professionals within general practice or the health system as a whole.

But how to define this? A general rule of thumb could be that GPs should not be providing protocol driven care, as this can be delivered by other members of the MDT or even AI.

However, this does not cover all the work that could be performed by other members of the MDT.

Another rule of thumb is that GPs should not be doing anything that a junior wouldn’t ask of a consultant – ie, organising blood tests. Generally, GPs should not be accepting any instruction from anybody to do something which they can do themselves.

Something that came through the previous panel, and the survey that followed, was that GPs’ expertise is in managing complex undifferentiated illness, and anything that doesn’t fall under this should not be dealt with by GPs.

It would be dangerous, however, to say that ‘minor illness’ is something that could be delegated – minor illnesses are only minor in retrospect, and one of the GP’s roles is to spot the major problem masquerading as a minor illness. And also there’s a big danger in minor illness being over medicalized and aggrandized unnecessarily, which is again something GPs can make sure doesn’t happen.

Communications with secondary care

If we take the conclusions above, something that would be absolutely essential is to improve communication between general practice and secondary care for when GPs do encounter something beyond their competence.

If there was a quick way of getting secondary care input that broke down barriers, GPs could carry out the complex care. Having that access to secondary care to allow GPs to get on with coordinating chronic and complex care.

Practice sizes

If general practice is to carry out all work that can be safely and adequately be done outside secondary care, then it would still be possible to operate in smaller practices. This could be done in a similar manner to the principle of primary care networks in England – actively encouraging collaboration between practices in order to offer greater services.

Our panel in full

Dr Nonso Anekwe, First Five GP in London

Dr Rehaan Ansari, ST3 GP in Lincoln, GP partner in APMS practice

Dr Katie Bramall-Stainer, chair, UK LMCs Conference

Karin Bruce, practice director, Jubilee Healthcare

Dr Richard Fieldhouse, chair, National Association of Sessional GPs

Dr Poppy Freeman, founder, Covid-19 Primary Care Resource website

Professor Clare Gerada, former chair of the RCGP

Dr Keith Hopcroft, Pulse clinical adviser

Dr John Hughes, chair, GP Survival

Dr Devina Maru, founder, Health Pioneers charity

Dr Sharon Raymond, director, Covid Crisis Rescue Foundation

Dr Kamal Sidhu, chair, British Association of Physicians of Indian Origin GP Forum

READERS' COMMENTS [4]

John Graham Munro 11 July, 2021 10:09 am

Thought Gerada would be there———how does she manage it all?

Andrew Jackson 12 July, 2021 9:04 am

An interesting survey but doesn’t take us any closer to work load control.
We (GPs) want to be first to see undifferentiated care because we are generalists and want to be excellent at it. We then want to manage the problem in a way that provides continuity.
This has always been the role of the GP historically but has fallen by the wayside as everyone becomes part time due to work intensity and we simply don’t have enough GPs to provide this.
We have to get more GP face to face sessions in the system and policies should support this.
How about you should never be able to earn more for a session of non face to face working than you would earn if you saw patients (this is the hardest part of the job after all)?

David Mummery 12 July, 2021 8:20 pm

The way to solve the workload crisis is make all GP Partners only paid for CLINICAL sessions ie. seeing and dealing with patients No GP should be paid partnership sessions for sitting in lots of stupid ( board, PCN, whatever…) meetings. Meetings can be done in lunchbreaks (and should be max 45mins)
Many GP partners pay themselves lots of partnership income for not seeing patients. Salaried GPs are generally only paid for patient-facing work. The same should apply to partners : if it did there would suddenly be a lot more GP clinical sessions!

Turn out The Lights 14 July, 2021 5:51 am

Pay for what is done stop the all you can eat block contract then you can pay more for clinical time rather than the admin BS.But your going to need a lot more GPS and a lot more funding.So the same is going to continue to the current service failure comes to its inevitable conclusion.