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Where have all the gatekeepers gone?

Our young GPs have a lot to learn to meet the commissioning challenge, says Dr Andrew Spooner.

The current generation of GP partners started with a vision of practice where a GP deals with most patients most of the time.

But young GPs are becoming deskilled in managing patients themselves. Changes to the contract made it financially difficult to bring new partners into practice, but the drivers of that policy are changing and partnerships are likely to become available again.

That will leave new doctors with the responsibility to drive practice development – but whether the outcome is an improvement will depend on what the new doctors actually do.

The evidence is that primary care focused on key aspects of patient-centred care is best for delivering good clinical outcomes, reducing health inequalities and controlling cost:

• first-contact access for each new need

• long-term care focused on the person, not disease

• comprehensive care for most health needs

• co-ordinated care.

Delivering this model of care is challenging. GP commissioning is an opportunity to re-establish the values of general practice – values that have benefited patients for a long time.

But my observation is that new doctors have been trained to refer a patient to multiple professionals in a scattergun approach. They are used to finding patient problems and dividing them between a range of specialists. Decisions off protocol are scary.

The organisation of hospitals also seems to encourage dispersal of a patient's care to multiple disconnected professions and to discourage GPs taking responsibility.

When young doctors come to practice, they lack the confidence to discuss simple advice on diet with patients or suggest changing the way a patient lifts in back pain. Without the limitation of being a specialist, alternatives can be discussed, more holistic solutions found, resulting in a more satisfied patient and reduced cost.

The lack of tenure makes that settling in period after qualification more difficult. And the plethora of centrally funded services in the community has encouraged this change in referral practice.

If we take more responsibility for care, it will make practice more clinically satisfying and patients will come back less often. Patients will increasingly value our opinion and not expect always to be referred to a specialist.

Commissioning, tight budgets and the requirements of the white paper to improve quality and reduce health inequalities all suggest we should now return to the core values of general practice. It is expensive to refer. Cost control will require a reduction in referral numbers.

Commissioning provides an opportunity to renew the values of general practice and help a new generation of doctors understand how to develop a satisfying career. One that is built around long-term relationships with patients that meet most of their needs and target use of other professionals to complex situations that can't be handled in general practice.

We can prepare for the challenges to come by helping future GPs to provide high-quality services that make the most of what we have to offer.

Dr Andrew Spooner is a GP in Crewe

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