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Roger Jones'1 gloomy prognostications about general practice and the health service show that fashion is cyclic. Sixteen years ago Duncan Keeley, writing in the BMJ, was equally anxious about the future of general practice and even predicted Professor Darzi's polyclinics.2 In the meantime general practice has flourished. Each contractual shift has induced a temporary dip in job satisfaction and a sustained increase in income, making British GPs the highest paid family doctors in Europe. A revolving door effect has meant that for every task acquired (like chronic disease management) another has been shed (like out-of-hours responsibilities) making work more intense but shorter in duration. GPs may grumble about being industrialised but they mostly accommodate to change and assimilate it, and get on with the job.
It is always tempting to portray GPs as doughty fighters for personalised and continuing care, struggling against the policies of insensitive and ignorant governments, but outsiders will see this as merely a disingenuous and self-serving ideology. Perhaps we should think uncomfortable thoughts rather than simplistic ones. First, the contractual relationship between general practice and the NHS inhibits investment rather than promotes it, leaving us under-equipped. Second, this results in a failure to modernise general practice fast enough to keep up with the expansion of medical knowledge and technology, in a rapidly changing society. Third, the gatekeeper function has all but collapsed in some places and in some clinical domains; at least a quarter of GP referrals to hospital chest clinics could be dealt with in general practice3 (if it were more skilled and better organised), and 40–80% of ENT referrals may be similar.4
If these thoughts are right, the position is untenable, but I cannot see how GPs can escape from it by enhancing their communication skills or claiming some special ‘biopsychosocial’ understanding that on closer examination looks quite superficial. Roger Jones is right that tenacity, commitment, and imagination are needed to sustain good quality general practice; but without investment in skills and technology, practices will not assimilate current changes. A systematic approach to increasing skills demands time rather than money, and is perfectly possible to do within practices. Investment in technology is a tougher decision but, in my view, the question for practices is not: ‘Can we afford to buy an ultrasound scanner?’, it is: ‘How can we not?’.