Multimorbidity may be stumbling block

There must be a continuation of the recent debate (1)(2)on the
changing roles and scope of practice of the GP as primary care in the UK
undertakes 'major experiments' including 'pay for performance' with the
quality and outcomes framework (QOF).(3) Scope of practice is generally
determined by the range of patients the GP cares for, the type of
investigations and procedures performed, the treatments provided, and the
practice environment.(4)

While positive impacts (such as greater consistency of chronic
disease practice activities) are emerging, these 'experiments' also have
unintended consequences. One consequence is a questioning of the role and
scope of the GP and the level of nurse substitution, because the major
work in the QOF is being carried out by practice nurses. Moreover other
reforms have impacted on the GP scope of practice. Hospital management,
rather than the GP, increasingly control access to the vast majority of
investigations, procedures and treatment resources through Referral
Management procedures and other constraints.(5)(6)

The range of patients in each practice shifts over time and varying
with population demographics and social determinants of health.
Addressing health disparities is a difficult to conceptualise and to
achieve.(6) At present there are few resources for the GP to adapt their
scope to address non medical health determinants and access at the
practice level.(7)(8)

Thus the type of investigations, procedures and treatments that the
GP provides, is shaped by the practice environment and the practice
population, and controlled by central and local policy on hospital,
community and primary care resources. What about the core competences,
skill levels and cost effective deployment of the GP?(9)

My recent experiences of front line general practice in England,
Australia and Canada, indicate that an unintended, but little talked
about, consequence of the UK experiment is the impact on the GP scope of
practice. In comparison to other countries, GP access to investigations,
procedures and treatments is curtailed and patients must be referred on
for straight forward care, despite the fact that GP is qualified to
undertake most work up activities.(10)This is particularly problematic for
those who are sicker with multiple morbidity who must do the rounds of
many specialities and sub-specialities on multiple disease and care
pathways. The usual solution to address this care in coordination is to
add a nurse to a team to co-ordinate care among multiple physicians and
other providers( 11). Another solution is to optimise the resources of the
GP and their full scope of practice so that fewer medical providers are
involved and relationship based care is preserved.(12)

The time is ripe for GPs to stand up in a positive rather than a
defensive manner for their own scope of practice. It is important to
elucidate professional constraints and boundaries in order to preserve an
acceptable high level scope of practice.

While QOF databases and systems in the UK, may be the envy of many
internationally, it would be a shame if these changes do not lead to the
most appropriate deployment of the highly cost-effective full scope of
skills and competencies of the general practitioner. While generalism
continually needs to be re-conceptualised in a complex, dynamic and
political health care environment, there must be some constraints to
ensure true value ensues from the GP role and expensive training.

(1) Sibbald B. Should primary care be nurse led? Yes. BMJ. 2008 Sep
4;337

(2) Knight R. Should primary care be nurse led? No.BMJ. 2008 Sep
4;337

(3) Godlee F. The world is watching the English experimentBMJ
2008;337:a953

(4)Physician Scope of Practice
http://www.cpso.on.ca/Info_physicians/scope/Scope%20Physicians%20Guide%2...

(5)Referral Management Principles
http://web.bma.org.uk/ap.nsf/Content/Referralmanagement?OpenDocument&Hig...

(6) Donnelly L. NHS managers blocked 75pc of GP referrals. The
Telegraph 29 Jul 2007. http://www.telegraph.co.uk/news/uknews/1558798/NHS-
managers-blocked-75pc-of-GP-referrals.html

(7) Saxena S, Car J, Eldred D, Soljak M, Majeed A. Practice size,
caseload, deprivation and quality of care of patients with coronary heart
disease, hypertension and stroke in primary care: national cross-sectional
study. BMC Health Serv Res. 2007 Jun 27;7:96.

(8) Low A, Low A. The QOF equity window: an illusion or a different
view? J Public Health (Oxf). 2006 Sep;28(3):293-4.

(9) Gravelle H, Morris S, Sutton M. Are family physicians good for
you? Endogenous doctor supply and individual health. Health Serv Res. 2008
Aug;43(4):1128-44. Epub 2008 Jan 31.

(10) Sharvill J Evidence for letter is lacking (12 October 2008)
http://www.bmj.com/cgi/eletters/337/oct06_1/a1975#203097

(11) Boult C, Karm L, Groves C. Improving Chronic Care: The "Guided
Care" Model. The Permanente Journal 2008;12(1):50-54.

(12) Martin CM. Chronic disease and illness care: adding principles
of family medicine to address ongoing health system redesign. Can Fam
Physician. 2007 Dec;53(12):2086-91.

Competing interests:
None declared