Future shape of general practice in England
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6268 (Published 21 October 2014) Cite this as: BMJ 2014;349:g6268
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In many parts of the UK, doctors are finding that the addition of Physician Associates to their healthcare teams is helping to make a dent in long wait times, take the pressure off harried staff, and allow them a little more time with their patients. There are currently five PA training programmes in the UK, with several more in the works. 200 Physician Associates currently work in general practice, urgent care, acute and chronic care, and specialities. They are mature, talented people with science backgrounds and, frequently, prior experience in health care. They generally have a commitment to staying in their (often underserved) communities. Their medical model training is intense and robust, and their assessment prior to practice is demanding and thorough. They offer continuity and deliver competent, safe, compassionate care alongside their physician supervisors and colleagues. The emergence of Physician Associates in the medical healthcare workforce is as inevitable as the inexorable increase in demand, and expanding access and providing more preventative and holistic care may help in the ultimate goal of encouraging and maintaining the good health and wellbeing of both our patients and their clinicians.
Competing interests: I am a US-trained Physician Assistant, born in the UK during the early years of the NHS to a solo practice GP father and a Nightingale mother.
Dr White and Dr Gillam consider the future of general practice without discussing what its role should be. Achieving the optimal balance between primary and secondary care is important but peripheral to this.
The fundamental difference between keeping the population healthy, and caring for the sick whose outcome should be measured by cure and failing that amelioration of suffering, is insufficiently recognised.
The former is a public health responsibility with the only proper outcome measure overall healthy survival, whilst caring for the sick should be judged by success by cure, and failing that, amelioration of suffering. Logically the interface with the former should be with general population and the latter with the individual. The two approaches require their own skills and their timescales, and therefore the financial implications, are very different. It follows that there is an inevitable and fundamental conflict of interest if one party is asked to do both.
Were general practitioners to concentrate predominately on treating the sick, the calling that motivated to become doctors and the task for which they are trained, this would be at the expense of time spent in attempting prevention. This might seem to be in conflict with the dictum ‘Prevention is better than Cure’, which is frequently interpreted as ‘Prevention is cheaper than Cure’. The original maxim might be generally true but should be applied with caution when approaching a healthy individual. It should not be at the price of an unhealthy obsession with disease or unpleasant side effects of ‘therapeutic’ interventions. The derived statement is a fallacy. The long-term global effect of successful interventions must always be the health gain and not financial saving. The ultimate financial outcome should always anticipated to be at best cost neutral, and costs are likely to be higher where the approach is to the individual rather through public health measures. It follows that general practice should concentrate on treatment, with the exception of the one intervention that is the exception to the dichotomy, amelioration of a clear-cut external hazard to the individual, immunisation. In contrast to the demonstrated futility of the current requirement to screen all adults between 40 and 70, all individual intervention should be carefully researched and justified by the evidence. If justified and appropriately conducted within general practice facilities, they should be commissioned by a public health body and fully resourced, not just financially, so as not to interfere with the prime function of general practice, treating the sick as much at home as possible.
Competing interests: Brought up over the shop of a single handed general practice
Re: Future shape of general practice in England
We were surprised that Gillam in discussing the future of general practice did not mention public health.(1) We believe that general practice has key roles to play in promoting health both at an individual and community level. There are many opportunities for promoting health in this setting but for many topics for effectiveness it is important that there is action in other settings as well, including: schools; workplaces; and hospitals. In relation to some of these settings there has been a considerable amount of academic literature produced, including theoretical papers, descriptive studies and evaluations. However, despite its central importance, the health-promoting general practice has received little attention.(2)
There are three criteria for creating health promoting settings: create a healthy work environment; integrate health promotion into activities; and, establish links with the community.(2) It has been known for a long time that the workplace can have a powerful effect on the health of individuals, both physical and psychological. Moreover guides are available for making the workplace more conducive to health.(3) However some would suggest that many general practices and hospitals are far from healthy places to work in.
NHS England’s Five Year Forward View proposes that we need a radical upgrade in prevention and public health and that they will support “comprehensive and hard-hitting” action to tackle priorities such as obesity, diabetes and inequalities.(4) One initiative is to provide incentives to encourage the NHS to be a healthier workplace. The document also highlights that primary care is central to targeted prevention, but at the same time admits that primary care has been under-resourced.
There is growing evidence that funding in general practice is lower than current needs: a shortfall of over 3000 GPs has been estimated.(5-8) Moreover, and critical for population health is the finding that under-doctored areas tend to be those with the greatest health needs.(5) With workforce shortages like these it should not be surprising to hear reports from general practice of stress and burn out.
Crucial to the future development of health promoting general practices and hospitals is government support, both in terms of enabling public health professionals to be facilitators of positive change and by providing different types of resources. For example, health promoting initiatives for staff will have little effect if they are undermined by a lack of staff to undertake the fundamental tasks.
References
1) Gillam S. Future shape of general practice in England. BMJ 2014;349:g6268 (21 October)
2) Watson, M., Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.
3) Faculty of Public Health and the Faculty of Occupational Medicine. Creating a healthy workplace: A guide for occupational safety and health professionals and employers. London: Faculty of Public Health, 2006
4) NHS England, Public Health England, Monitor, Care Quality Commission, Health Education England. Five year forward view. October 2014. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf.
5) Goddard M, Gravelle H, Hole A, Marini G. Where did all the GPs go? Increasing supply and geographical equity in England and Scotland. Journal of Health Services Research & Policy. 2010. 15(1): 28–35.
6) Centre for Workforce Intelligence. In-depth review of the general practitioner workforce. 2014. www.cfwi.org.uk/publications/in-depth-review-of-the-gp-workforce.
7) NHS GP Taskforce. Securing the future GP workforce—delivering the mandate on GP expansion. 2014. http://hee.nhs.uk/wp-content/uploads/sites/321/2014/07/GP-Taskforce-repo....
8) Limb M. Increase GP trainees by 450 a year to avoid crisis, says taskforce. BMJ2014;349:g4799.
Competing interests: No competing interests