I read an article the other week by Matthew Parris, in the Times – not a paper I usually read, but still, I read it on this occasion! He was, I suppose, imagining a future without General Practice within the NHS and was of the persuasion that GP’s have had their day and are now no more than glorified ushers/gatekeepers into the ‘real deal’. He was of the opinion that people really want to see specialists and that generalists are a bit of a waste of space, time and money and would prefer the family doctor to be replaced by a family nurse. (I think we need both!). As an aside, he also doesn’t mention that this is entirely unaffordable and actually leads to worse care for the majority in the long run!
It got my cockles up, to say the least! I fear that he has somewhat missed the point of General Practice – what it is that actually goes on in our consulting rooms. Mr Parris doesn’t suffer from a chronic disease like COPD or diabetes or with the multiple pathologies that accompany them, apparently. His life isn’t falling apart and he isn’t unsure of who else to turn to with enough of a skill mix and position within the community to be able to help out on several levels. He hasn’t had a major diagnosis of a significant illness, be that a neurological issue, like MS or MND or an aggressive lymphoma or bowel cancer. He isn’t a drug addict with a complex personality disorder. He is unlikely to suffer from a severe and enduring mental illness. He doesn’t appear to have a skin disorder (many of which can mimic one another) needing regular reviews and clear management plans. He is unlikely to have chronic pain. He may not suffer with migraines or other headaches, ENT issues, recurrent bladder infections or a frozen shoulder. currently, he does not need palliative care co-ordinating so that he can die peacefully at home. I don’t think he will need to bring his children along for their 8 week check, immunisations, reassurance over coughs and colds, behavioural problems, developmental issues, constipation, soiling, acne – the list goes on. I see these kinds of things every single day, and not one of my patients regrets having to see me, as I have the privilege of having an overview of all the various things they have going on. I’m quite glad of my medical degree, extensive and varied speciality training over several years so that I can utilise this toolkit for whoever walks through my door! A good generalist, pursuing excellence in their career, with honed communication skills and a passion to serve and love people is, in my (extremely) biased opinion a vital foundation stone within any health system – particularly one that wishes to serve the poorest and most vulnerable people within our society. There is an ability within general practice to have a good depth of knowledge about a vast array of differing medical and non-medical issues which serves as a vital welcoming, gatekeeping and sometimes blockage to other services. In turn this gives us the ability to ensure that every person, no matter how much money they have, is entitled to a fantastic standard of healthcare which will be sustainable for generations to come. My plea here, I guess, is to honour the role that general practice plays – it is so much more complex than the article allows us to believe.
However, I do think that Matthew makes an important challenge, because once you get past Mr Parris’ rant over general practice, he unearths a problem (although I don’t know if this was his intention!), that needs discussion. It is the issue of walls! Walls, barriers, blockades, fences, call them what you will but there is just a whole bunch of stuff that divides primary (community) and secondary (hospital) care currently in a very unhelpful way (and don’t get me started on what is going on right now to the various vital therapies – more on this another time!). In the final analysis these walls mean that patient care suffers and there is a severe lack of continuity in that care. I think we need to learn to be a whole lot less territorial and learn that new levels of partnership between primary and secondary care are vital. The future is calling for new integration, where GPs can continue their care of patients into the hospital setting with far greater access to diagnostics (used appropriately) and hospital staff can step out of the huge monolithic hospitals back into the real world of healthcare in the community, for the community; where patients are not just targets to be met, but real people again, empowered to make choices about their health and futures.
If we are to reimagine the future of healthcare in this country, one of our starting places must be to imagine a culture without walls. A culture with teamwork and honouring of everybody’s various roles. Humility is the key to embracing change. Humility to let go of power in the pursuit of service. Humility to work together and not need to create a great name for ourselves. Humility to climb out of our ivory towers and important chairs and to normalise ourselves…..to re-embrace the reasons that we went into healthcare, before we got burnt out and cynical – a love-based ethic in which everybody matters the same! Let the walls and the towers come down. We must strengthen again the foundations. For me, one of these is good community medicine…….the day of the GP isn’t over, but a new day of integrated care and partnership is here. We will, quite rightly see a greater role for our wonderfully skilled nursing colleagues and this will mean letting go of some of our preconceived rights as doctors! Maybe we all need to be willing to let go of some of the tradition of our roles to find a new future (please no more arguments over who should be feeding patients, cleaning up vomit or making beds – if the need is there – meet it, whoever you are and whatever your role!…..will we still need GP’s in 30 years? – I believe we will. Will we still need specialists? I believe we will! Will there be a blurring of the boundaries, a breaking down of the walls and new definition coming to all of this? Yes, I believe there needs to be…….reimagine the future!
Andy. Great stuff. Love your thoughts. Love the forum and debate. Love the ability to share some of my own ideas with an eclectic mix of readers.
I heard a stat the other day that should have shocked me. “on average GPs diagnose correctly six times in every ten.” That suggests there can certainly be improvements to the way our community care works and how GPs operate.
That said, I think the role of the GP is critical in so many ways:
– It is in and involved in community. Taking another piece of the community heart beat away would be a bad thing.
– one health problem can often be caused by other factors and a wholistic approach to an individual’s health needs to be considered.
– community care is a lot more cost effective than in hospitals. The more we can do in the community (with the GP as the hub – or custodian / guardian if you like) the better.
– there not only needs to be a coming together of primary and secondary care but also social care. The lines are very blurred and distinct organisations, budgets and agendas means people and care falls through the gaps.
A valid case study is the banking system, where once upon a time a banker would spend the best part of his career moving around a bank, gaining experience of all it’s operations and along the way understanding how one area impacts another. However, as everything became more technical bankers were asked to specialise more early… to the point where kids at 22 yrs old knew only about their niche derivative area and didn’t understand it’s part in the eco system. Needless to say the fragmented structures became more fragile, risk built up without anyone realising and the rest is history.
Specialisation can be fantastic and has its place but I do not think a system as complex as banking or the health service can operate correctly without the oil that greases the whole system.
Thanks for the reply – I totally agree!