Professor Martin Marshall
Lead, Improvement Science London
At times of crisis it’s easy to hunker down, to become inward looking. But if general practice responds defensively to the major challenges of increasing workload, reducing funding and ill-informed criticisms by the media and politicians, then matters will get worse. It is time to go on the offensive, to clarify why a vibrant general practice is essential not only to individual patients and to the communities that they operate in, but also to the very survival of the NHS. Four roles that general practice fulfils, day in and day out, are particularly important.
First, general practice is the part of the NHS where uncertainty is acknowledged and risk is managed. In contrast to hospital practice, there is a low probability of disease in patients seen in general practice. It has been estimated that more than 60 per cent of presentations in general practice cannot be explained in terms of recognised disease processes. Policy makers incorrectly interpret this as GPs being over-skilled for much of their work but in doing so they fail to understand the level of sophistication required to make judgements about when to investigate and when to reassure. If GPs referred all people with potentially dangerous symptoms and signs to hospital, the NHS would implode in weeks. Occasionally GPs get it wrong, the vast majority of times they get it spot on.
Second, general practice is the part of the NHS where the interface between professionalised care and self-care is managed. Self-care of the symptoms and signs of ill-health is infinitely more common than care provided by health professionals. Minor changes in people’s help-seeking behaviours can have a massive impact on the use of NHS resources. There are therefore practical as well as philosophical reasons for encouraging a high level of shared care and informed self-management, particularly for people with long term conditions. Promoting self-care effectively requires the deep understanding that GPs have of individual’s health beliefs and the environment that they live in, as well as technical expertise in encouraging behaviour change. GPs play an essential role if policies promoting shared and self-care are to be delivered.
Third, general practice is the place where the up-stream determinants of health are recognised and managed. The environmental and behavioural determinants of ill-health, such as poor housing, unemployment, diet, exercise and stress are widely recognised but highly resistant to remedial action. As members of the communities that they serve, GPs have a deep understanding of what needs to be done as well as having the trust of patients to lead change. General practice is public health with a personal touch.
Finally, general practice is the part of the NHS where the tensions inherent in the multi-dimensional approach to quality are handled. Hospital specialists rightly focus on the clinical effectiveness and safety of the care that they provide – this is what patients want and need when they go to hospital. But someone in the health system needs to bring a balanced view of quality, managing what are sometimes trade-offs between good clinical outcomes and waiting times, between providing safe care and the costs of minimising risk, between meeting the preferences of individuals and ensuring fairness to everyone. Taking responsibility for these trade-offs is neither easy nor popular but GPs do it effectively every day.
General practice will not be able to continue carrying out these roles without a bigger share of NHS resources, without spending more time with individual patients, and without a workforce that has a high level of self-confidence and morale. This is why the RCGP’s campaign for the future of general practice, Put Patients First, requires everyone’s active support.