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100 Words: The Future Roles of General Practitioners

Various
Contact the authors by e-mail at christopher.johnstone@ntlworld.com

Following the College’s successful work with practice accreditation and other clinical aspects of General Practice it decided to look at the more the softer end of what makes a good GP or even an excellent GP. RCGP Scotland asked a number of leading lights of the GP world how they saw the Future Roles of GPs in 100 words. Here are their replies:

Professor Julian Tudor Hart

Retreat of public medical care to corporate trade devalues the generalist role of GPs, encouraging them to hand this to nurses with even narrower education, and retreat to imitative roles as intermediate mini-specialists. Their future depends on whether they and their patients resist marketisation of public service, or return to the hard path we ascended from 1952, until the purchaser-provider split pushed marketing into public service. We were originally headed toward a distant goal: human biologists embedded within communities, not only treating, but preventing, teaching and researching, and needing more scientifically rigorous education and imagination than any other calling.

Dr David Pendleton

Tomorrow's General Practitioner will need to resolve matters that may be described by two intersecting dimensions: care and organisation. Care encompasses values, skills/knowledge and professional development. Organisation covers issues from the structure and ownership of practices, to matters of efficiency and cost. Both dimensions have to be resolved if general practice is to be sustainable both for the nation and for the participants (workers and patients). Cost pressures could force general practice into a low care model also, and these pressures have to be resisted. High care does not have to mean high cost, however, if we can become more creative and skilful about how we manage our organisations. We owe it to our patients, ourselves and our nation's tax payers to resolve these matters well.

Dr Iain Bamforth

The GP and the idioms of medicine.
One thing is clear: the future GP will have to be polyglot, attuned to the many idioms of medicine. Not just the familiar ones of biomechanics and biography, but those of (human rights) law and contract, redefining what is meant by trust; and, since we all want choices, those of civil liberties and managerialism, media and marketplace. Patients have their network jargons too. Only one language is inadmissible: that of the benign partisanship that once allowed GPs to act as their patients’ ÒadvocatesÓ. The paradox is that paternalism is now the State’s prerogative, a kind of Newspeak we might feel disinclined to learn. But we cannot ignore it.

Professor James Willis

The role of general practitioner has not changed. It is open-ended, inclusive rather than exclusive, dealing in wholes not parts. It is personal, it is continuing, it means making the patients feel you care about each one of them, it is about respect, trust, independence and personal integrity. It is founded on science, and yes, yes, evidence, but it also involves the reconciliation of incompatibles, irrationalities and impossible expectations. It rejects the inhuman and the formulaic. It involves privileged access to other people’s deepest secrets, their bodies, and yes, their homes. Will future doctors leave this natural niche unfilled?

Professor Ian McWhinney

1. Stick to our principles (even thought it hurts) - especially being generalists. If we break up into specialties we are lost.
2. Prepare to deal with acute illness in the home; as MERSA gets worse, home care will grow.
3. Be serious about "ethical repair" in our own profession.
4. Become more knowledgeable about the emotions - our patient's and our own. The emotions, both expressed and hidden, are a huge part of most illnesses. We should be the leaders in this. Balint wrote the book on this and it is still relevant.

Professor David Haslam

In a time of increasingly specialisation and an era when patients and the public will increasingly and understandably demand the very best of care, generalists and their educators must focus on: The evidence for generalism. Ensuring that, even if some specialists still put general practice down and denigrate it as a career choice, thoughtful students see through such absurd prejudice. Building humble self belief in generalists. Focusing on the importance of whole-person care. Ensuring that they focus on people and not diseases. Genuine communication skills. Recognising what to do when you don’t know what to do. Maintaining enthusiasm.

Dr John Horder

The most critical choices facing future students and educators creating GPs of the future. ('Choice' in this context must usually mean, not 'either/or' but 'optimal balance between...') The choice i.e. optimal balance:

• Between the interpersonal and the technical aspects of generalist practice, education and research.
• Between one-to-one patient relationships and the teamwork required by technical developments and time pressures.
• Between the essential generalist/comprehensive role and the degree of specialisation allowed within a group or team in primary care.
• Between the proportion of time given in the consultation to listening and discussion versus using and creating computerised information.
• Between relational and informational patient Ð doctor continuity of care.

Professor Graham Watt

The consultation is the comfort zone for general practitioners, where ethos, experience, skills and aspirations all come together. The consultation is essential, but insufficient as a basis for considering the future of general practice and primary care. The practice is another field of play - originally a straightforward business, but increasingly, a complex micro-economy, working differently with almost everybody, and with a huge capability and responsibility to improve health, mostly via population approaches to every level of prevention. General practice has become a social enterprise. Retaining leadership in primary care depends on how fully and imaginatively general practitioners adapt to this challenge.

Professor Trisha Greenhalgh

The most critical choices facing future students and educators creating GPs of the future.Three key choices for educators:

1. 'Behaviourist' versus 'humanist' philosophy. Do we focus on improving performance against objectively measurable indicators or on developing professional virtues which can only ever be measured indirectly and subjectively? And if 'a bit of both', what is the most appropriate balance?
2. Educator's role. In all areas of education, there is a move from 'sage on the stage' to 'guide on the side' and perhaps even 'host on the post'.
3. Medium. High-tech versus low-tech? How and to what extent might online methods (universally accessible, timeless, spaceless, archivable, potentially image-rich and multi-channel) replace and/or supplement face-to-face meetings ('high bandwidth' interaction that everyone understands)?

Professor David Metcalfe

The most critical choices facing future students and educators creating GPs of the future. However the NHS is organised the GP will still have two crucial responsibilities: to use high clinical skills to diagnose or safely exclude serious illness in people presenting for the first time, and to manage the care of people with chronic illness, in both situations sensitively to the patient as a person. Educational objectives, content and method must be chosen with these skills and their practice a central priority. All other matters (practice organisation) should provide the platform for good consultations.

Professor James Dunbar

The projections for the global burden of disease predict an epidemic of diabetes, metabolic syndrome, cardiovascular disease and depression. General Practice will have to improve its outcomes for patients with chronic diseases. Co-ordinated team care will become a necessity. The emphasis will be on bringing about lifestyle changes. It will prove impossible for this to happen within the NHS. It will be replaced by not-for-profit Health Maintenance Organisations which will prove far more successful at delivering all forms of care to the entire population with higher clinical outcomes and lower costs. Memories of the NHS will rapidly recede into history.

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.