A report published today by the Nuffield Trust looks at the changes which are occurring within general practice, and the impact they will have upon the ‘medical generalism’ which is currently the traditional role and strength of general practice.
New models of care, with a focus on faster access and transactional consultations, (such as walk-in centres for patients who prioritise convenience and speed of access, or specialist frailty centres for older patients with multimorbidities and complex needs), are diluting the traditional medical generalist role of general practice by segmenting different patient groups, and adapting services to meet their particular needs.
General Practice is usually associated with a list-based approach which provides a GP with a good knowledge of the patient and their family, including social, environmental and employment factors. This allows the GP to adopt a more holistic approach to the understanding and interpretation of symptoms, and facilitates their judgement of clinical risk within the community setting – thus reducing the need for onward referral. For some patients this allows a GP to ‘de-medicalise’ a problem where medicine may not be the answer.
The role of the GP as a gatekeeper is important in health systems such as the NHS, as it supports better health outcomes at lower cost, due to fewer requests for diagnostics and procedures, as well as fewer referrals due to continuity of care.
However, as pressures increase within general practice, there is a need to clarify exactly what we want general practice to deliver. This clarity requires an understanding of the advantages and trade-offs of care model changes. For example, the current emphasis on timely and convenient access will result in fewer resources being left to deliver the generalist and multi-disciplinary care aspect of the service. Similarly, a focus on technology to improve access, may result in a supply-led increase in demand; therefore, it is important to step back and rationalise where the use of technology can achieve the best results, (e.g. in long-term conditions monitoring), rather than it simply adding extra work, with little benefit to either patients or staff.
There is a need to understand and be able to identify patients who will benefit from a transactional type service, and those who will require the more traditional medical generalist/multi-disciplinary service. Technology which analyses clinical data and use of services could potentially fulfil this signposting role.
General Practice is under pressure, and there is a growing number of part-time GPs which means continuity of care is not always possible. Adopting a team-based approach to continuity may be the answer, with the inclusion of nurses and other health professions in these teams. Medical training for GPs needs to reflect the changing nature of general practice.
This report concludes by stating that comparisons of outcomes and care costs for specific conditions treated in different forms of segmented primary care are needed to support future general practice care models. These future models should aim to have the capability, (using technology), to be able to direct patients to either enhanced access or generalist medical care, dependent upon clinical need, all provided by a single integrated organisation.
To read this excellent research report from the Nuffield Trust in full please click here.