CONCEPTUAL, INSPIRATIONAL, EDUCATIONAL
PERSPECTIVES, GUIDANCE.
Since the time of Hippocrates, the forerunner of all medical practice could be said to be the general practitioner (GP). Indeed the ‘Hippocratic Oath’ emphasises perhaps a key feature of the GP, that of looking after patients in their home and community:
“Into whatever homes I go, I will enter them for the benefit of the sick”.1
However even at that stage a distinction between generalists and specialists was drawn:
“I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft”.
In the United Kingdom it was under the National Insurance Act of 1911 that the role of the general practitioner first became formalised as a discipline, providing much needed first-contact (‘Primary’) care to all those on their personal list of registered patients. This was a key public health role aimed at tackling deprivation and health inequalities. Over the coming decades, with the expansion of research and the technical development of medicine, specialisation developed as a way of managing the complexity of provision. Secondary care doctors became trained, not just in the major specialities such as internal medicine and surgery but subspecialties such as cardiology and haematology. Over time through the process of specialisation and sub-specialisation, healthcare began to fragment. By 1948 at the birth of the National Health Service, general practitioners, those who had chosen to focus on broad-based generalist primary care, were tasked with a key role not only as a provider of care, free at the point of delivery, but also to help the patient negotiate this fragmented, complex healthcare landscape. GPs became ‘gate-keepers’, if specialist or in-patient care was needed. This system of professional referral is still key to equitable provision of medical services in the UK, but at the start it was poorly thought through and generated an enormous workload for general practitioners who were not trained (or paid) for the administrative burden. Within one month of the birth of the NHS, 90% of the population was registered with a GP, and could not access secondary or tertiary care except through GP referral. The profession rapidly became overwhelmed by the demand. This new, organisational aspect, of general practice led to the demoralisation of overworked general practitioners and clinical standards suffered.
In 1950 The Lancet carried a damning report into the standards of British General Practice by a visiting Australian academic. In response a group of GPs and specialists led by Dr John Hunt convened a group, which in 1952 was to become the College of General Practice. From the very start the College had a two-pronged focus on GP-specific education and research. It is important to note that in those early days hospital specialists were key allies in the development of the discipline. Although not universally understood there was a recognition by some leading figures across healthcare that general practice was a distinct discipline requiring its own research and evidencebase and needing a particular type of training.
By 1966 two changes set the foundation for the development of a modern general practice in the UK. Firstly the government introduced a new national GP contract under which lists were limited to 2000 patients per GP and funding was allocated for continuing professional development, the development of suitable premises and expansion of practice teams. Second, the College’s emphasis on training led to the submission of evidence to the Royal Commission on Medical Education. By 1976 it became illegal to set up as a GP without three years of specific postgraduate training leading to licensing as a GP. The College of GPs, which gained a Royal charter to become the Royal College of GPs in 1972, focussed on postgraduate training emphasising the art of generalism to develop doctors who could focus on holistic, person-centered care. GPs became patient advocates in the appropriate access to care, 90% of that care however still being delivered by GPs as leaders of primary care teams. Undergraduate curricula began to develop to include the evidence for and function of primary care, including the technical skills of consulting, ensuring that all newly graduating doctors had an understanding of the distinct role GPs played in the public health.
A strong research base developed, describing the benefit of robust systems of general practice and primary care. As Starfield summarised in 2009 “Too few true generalists and a surfeit of specialists is bad for population health, bad for the economy, and even worse for health equity.” 2
Evidence for the benefits of primary care-oriented health systems is robust across a wide variety of types of studies. As the work of Starfield and others has shown, it can be seen in international comparisons, in population studies within countries or across areas with different primary care physician to population ratios and in studies of people having first-contact with different types of practitioners. Similarly the benefits can be seen in clinical studies of people going to facilities or practitioners differing in adherence to primary care practices.
As the technical sub-specialities of medicine developed it also became clear that in a publically funded system of socialised healthcare, the costs needed to be managed. First contact primary care can be shown to avoid unnecessary specialist visits, freeing up specialist provision for those who need it and reducing costs by targeting specialist provision. It also enables person-focused care over time which avoids disease-focused care making care more effective 3 . A comprehensive primary care service avoids referrals for common needs which also makes care more efficient. Having GPs as coordinators of care avoids duplication and conflicting interventions, making care less dangerous. The cost-effectiveness of primary care is demonstrated by an oft quoted statistic that general practice in the NHS accounts for 90 per cent of patient consultations and just below 8 per cent of the total NHS budget.
Self-regulation by referrers however came to be seen by the UK government as insufficient to manage costs. The approach to public sector reform and the modernisation of public services through the 1980s and 1990s was one of performance accountability. A ‘purchaser-provider’ split was set up to involve doctors in the two sides of provision and commission of services. One unintended consequences of this was the risk of a perverse incentive for hospitals to perform excessive and unnecessary investigations and procedures to increase their income at the expense of the primary care sector. The model allowed for “any willing provider” and clinics, including those in primary care, started to develop services to deliver low cost, high volume procedures. The overall response led to a spirit of competition rather than collaboration.
This unhelpful competition was tackled in 2014 through the most recent phase of UK NHS reform called the Five Year Forward View which set out to tackle the growing number of patients with multiple co-morbidities and long-term conditions, territory ideally suited to the ‘specialistgeneralists’ working in primary care. The plan was that a single organisation in a locality would take responsibility for delivering the range of primary, community, mental health and hospital services removing the boundaries between mental and physical health, primary and specialist services, health and social care. It is still not clear what overall impact this is having on population health, but it is an era of renewed interest in and funding for primary care.
General practitioners are increasingly members of expanding multi-professional teams. They frequently lead or coordinate those teams and are involved in health service management and organisational aspects of service design and medical politics as well as clinical leadership and educational roles. They oversee considerable resource allocation and budgetary control with responsibility for large numbers of staff.
Whilst the political and organisational landscape GPs work in continues to change and develop, presenting new and ever more complex challenges, at the heart of the role remains a core professional responsibility: to the patient in front of them. This has not changed from the times of Hippocrates, and brings a focus on a promise to
“…benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them”. 1
FAMILY MEDICINE & PRIMARY CARE
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