The essentials of General Practice

I’ve been thinking very hard about how we support GPs in the essentials of their work, and been inspired by a couple of things this week.  One is the best single page summary of GP work I’ve ever seen, to which I’ll return, the other perhaps surprisingly is the GMS contract which covers the vast majority of UK GPs (with PMS which borrows most of it).

Wrapped as they are in reams of clauses, the essentials of the GMS contract are wonderfully simple.  The suitably qualified contractor, ie a GP, must provide services for the management of “their registered patients who are, or believe themselves to be, ill” (whether temporarily, terminally or chronically).

It is entirely at the patient’s discretion to decide they need help.  It is in our terms demand-led, not limited by the contractor’s slots, appointments or whatever they choose to call their capacity.  Such an open ended commitment sounds impossible but…

It is entirely at the GPs discretion to decide on the management, which might include consultation, examination, treatment, care or referal as appropriate, delivered in the manner determined by the practice in discussion with the patient”. Even the “when” is “within core hours, as are appropriate to meet the reasonable needs of its patients.”  Who decides what is reasonable?

I think the contract works because it is open ended.  It relies on good will, the professional ethos of GPs and the trust of patients that their needs will be met.  Yes, it is abused by some patients and some GPs, but that’s humanity.

NHS general practice is the envy of the world because it is local, freely available and relationship based.  It is under threat by those trying to dumb it down to transactions, or replace with non-GPs, anon-GPs or computers.  Its resources are being squandered on longer hours instead of responding to demand, on costly and unevidenced economies of scale when we need continuity and economies of flow.

By the way, in terms of system flow the fact that over 95% of undifferentiated medical demand is resolved within the ordinary, average practice is astonishing.

Now to that one pager, in this week’s BMJ Dr Phil Whitaker gives us the NHS GP caring for the whole person, and simply a must read.  “Interpreter, medical generalist, player-manager . . . on top of these, the GP is an expert friend.”

The essence of general practice is enabled by a contract, but it can’t be written into a contract.  The crisis in general practice can’t be fixed by fiddling with the contract or diluting the essence.

We are fixing it by working on the system at practice level, understanding demand, flow, outcomes and how to create change.  And we do need to change, in order to stay the same, true to the principles of universal, high quality primary care, free at the point of use.

Harry Longman

One response to “The essentials of General Practice”

  1. Allen Wenner says:

    The US squanders billions of dollars annually in health care delivery because of the concerns you raise. The US reimbursement system counts only transactions for payment. Primary care doctors (PCPs), the GP equivalent, have been replaced with mid-level providers (MLPs). MLPs can handle a far lower percentage than 95% of medical demand so they order far more unnecessary tests and unneeded referrals. These referrals are very profitable for the health care system, but worthless, expensive, or dangerous for patients. Non-visit care in the US is either free (telephone consult) or illegal (e-visits). Patients are left to become their own doctor. Health quality and access is deteriorating for much of the US population. The UK approach of global payment is now being considered in the US.

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