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



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.