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Over the past 5 years, general practice in the UK has undergone major change. Starting with the introduction of the new GMS contract in 2004, it has continued apace with the establishment of Postgraduate Medical Education Training Board, a GP training curriculum, and nMRCGP. The NHS is developing very differently in the four countries of the UK. Regulation of the profession is under review, and a system of relicensing, recertification, and revalidation is being introduced. The Essence project, initiated by RCGP Scotland in conjunction with International Futures Forum 4 years ago is a constructive response to these changes. It has included learning journeys, a discussion day for GPs, and commissioned short pieces of 100 words from GPs and patients. From an analysis of these, some characteristics of the essence of general practice have been defined. These include key roles and core personal qualities for GPs. It is argued that general practice has important and unique advantages — trust, coordination, continuity, flexibility, universal coverage, and leadership — which mean that it should continue to be central to the development of primary care throughout the UK.
‘The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty. As our case is new, we must think anew and act anew.’ (Abraham Lincoln)
‘Essence: that which constitutes the being of a thing; that by which it is what it is.’ (Oxford English Dictionary, page 896.)
General practice as a discipline has made considerable strides forward over the past three decades. There is good evidence that well-developed general practice and primary care systems can improve quality of care within a health system.1 The discipline of general practice has been closely examined and defined,2 and in the UK a training curriculum proposed by the Royal College of General Practitioners (RCGP)3 has been approved by the Postgraduate Medical Education Training Board (PMETB).4 A new entry examination, nMRCGP, based on the new curriculum, has been established. The new general medical services (nGMS) contract is largely evidence based,5 in that most of the targeted areas within the Quality and Outcomes Framework (QOF) are directly or indirectly supported by evidence from randomised controlled trials and, if achieved, are expected to improve individual and population health. Contrary to expectations, practices have responded to its introduction by achieving high scores in the QOF. This development, unique in general practice, is being watched with interest in many other countries.6
Although the QOF covers many important aspects of care, GPs also recognise that the inherent strength and complexity of the doctor–patient relationship supports quality at a much deeper level.7,8 There are growing anxieties that the focus on the QOF, driven by financial incentives, may lead to the loss of something important but hard to measure in general practice.8–11 This is an unsettling environment for patients and doctors. In addition, recent devolution and political changes in the UK mean that four widely different NHSs are emerging, in Scotland, England, Wales, and Northern Ireland. While each of them is still founded on Bevan's philosophy, the four countries of the UK have increasingly different approaches and institutional frameworks to deliver health services.12,13 With a nationalist government in Scotland and a clear move towards privatisation and disaggregation of the NHS in England, this divergence is likely to increase over the next few years. There are also many other changes in society and within the profession that challenge the current position of general practice. Some of these are summarised in Box 1.
This divergence in policy and delivery makes it even more important that GPs and patients try to define and enhance the ‘essence’ of general practice lest it becomes lost in the plethora of changing organisational structures that characterise the NHS today. This paper is an attempt not to preserve or maintain a mythical ‘golden age’, but to look critically at current developments, explore ideas, and suggest possible ways forward for general practice that both provide continuity with past traditions and engage constructively with the rapidly changing worlds of evidence, technology, and contemporary culture. In doing so, it was hoped that some characteristics of the essence of general practice would be defined.
Conventional responses may be inadequate in helping the profession to respond effectively to this continuing and unpredictable change. Because of this, a collaboration has been formed with the International Futures Forum (IFF) (a non-profit organisation ‘that exists to develop the capacity to sustain human aspiration, realised through wise action, in a complex and challenging world’).14 Novel methods have been employed, and previously piloted to examine public health in Scotland,15 to look critically at current developments.
The methodology has included learning journeys, a discussion day, and commissioned short pieces of 100 words from GPs and patients. It began by asking, through learning journeys (Figure 1): how are we addressing the complexity, change, and uncertainty of early 21st century general practice?
Two learning journeys were carried out and a discussion day was held. Detailed information on the process is available in Appendix 1. The first was for members of the group who visited two sites: a day centre for the over 50s in an urban area of high deprivation, which had thrived through a period when many better-funded, similar organisations had failed, and a large national organisation which was subject to both market forces and considerable government oversight and regulation.
Over the past 10 years, general practice in the UK has undergone major changes in education and training, workforce characteristics, and contractual arrangements. These have occurred against a background of rapid societal change, and produced uncertainty and a feeling of loss among many GPs. There is little published literature looking critically at the consequences of these current developments and so exploring the core values of general practice with an emphasis on the future. This study uses innovative methodology to examine this area. From this work important key roles for future GPs have been derived and a summary of personal qualities required. This study suggests that general practice should continue to be central to the development of health care because only general practice offers the key advantages of trust, coordination, continuity, flexibility, universal coverage, and leadership. Challenges for GPs include that of retaining their role in changing times, raising quality across the whole of the GP spectrum, and grasping the potential for leadership that is now being presented.
The second learning journey was organised for GP registrars and trainers based in a Scottish deanery. The aim was to use these journeys as a basis for reflection on what GPs do and how they should be trained in future. The three locations chosen were the Homeless World Cup Centre,16 the human resources division of a large NHS Scotland organisation, and the telephone banking division of a major UK bank. Extensive contemporaneous notes were made and circulated among the learning journey participants. Feedback and further discussion refined the material. The main learning points are summarised in Box 2.
This all-day meeting, organised to encourage freedom of expression and frank discussion,17 was organised by IFF in association with the section of General Practice and Primary Care, University of Glasgow, and RCGP Scotland. Full details on the process and analysis are in Appendix 2. Forty invited GPs, a psychologist, and a poet took part. Most of the day was spent exploring issues in small, often impassioned, groups. In addition a series of 16 100-word summaries on the future of general practice, obtained from prominent GPs, was circulated to participants prior to the meeting, and attached to the walls of the room to stimulate discussion. Following the meeting, the patient group of RCGP Scotland was asked for a similar series of 100 words. The full text of all 25 statements is available as a set of prompt cards, developed as learning tools for GPs.18
The fact that the NHS still provides contact, universal coverage, and a variable degree of continuity, without financial barriers for patients, was regarded as a major achievement. However, the ‘inverse care law’ still persists.19,20 The rapid and repeated organisational change that has characterised the NHS for many years was felt to consume rather than generate energy,21 often undermining creative initiatives in general practice before they had a chance to deliver. There was also concern that the NHS has become too risk-averse:
‘All good learning embraces the possibility of failure, yet we persist in a culture that has at root the delusion that it is possible to develop failsafe, foolproof systems.’ (GP)
There was also a widespread feeling that the NHS — large, bureaucratic, and slow to respond — fails to understand general practice — small, dispersed, and often engaged with local communities.22 There was a consensus that discussions on the future should reflect the GMS contract but that contracts should be used to enable rather than limit developments in general practice.
There is an unacknowledged tension between profit and service in general practice, which leads to difficult decisions over investment in staff and services. Successful adaptation to future challenges needs local GP leaders who have vision, and can see the opportunities ahead and respond in a way that does not compromise core values. Much discussion was generated by the visit to the Homeless World Cup Centre.16 This discussion related to what was seen as the under-realised potential of GPs to engage more fully, as social entrepreneurs, with communities, voluntary organisations, and other businesses. Obstacles to this were seen to be time and lack of incentivisation of this potential by NHS structures.
Extended teamwork was seen as essential to the functioning of a modern NHS, and general practice is well placed to be central to much of that. However, there were tensions between the need for effective teamwork and patients' wish to relate to and sometimes see their own GP, rather than another team member.
There was consensus that the advent of evidence-based medicine had transformed the clinical effectiveness of general practice, and that the evidence-based incentives in nGMS are likely to produce public health benefit, yet concern that certain individual patients may benefit little from this:
‘Incentives do work: nGMS will save lives and produce better care, but drives the doctor's agenda, not the patient's.’ (GP)
Concerns were also expressed around the status and use of the word ‘evidence’. GPs work in a complex social system. Clinical judgment is often based on weighing different types of evidence. Evidence adds to understanding and clinical reasoning, but does not replace it. It was not seen as a simple and emphatic driver for the future of high-quality general practice.
Tension between a focus on interpersonal relationships and the increasing use and potentially dehumanising effects of information technology was a common theme throughout the project. Worries were also raised about the growing medicalisation of populations. There was also concern that registration with a practice rather than a GP was driving a two-tier pay and power structure — powerful executive principals and younger subservient salaried partners, in which the latter felt disengaged, not valued, and at risk of exploitation.
Being a General Practitioner, the core statement of the nMRCGP curriculum,3 contains a daunting 75 learning outcomes for GP trainees. Concern was expressed by both registrars and trainers about whether it is possible to create, within a limited time-based training programme, a GP who is fully aware of and engaged with these outcomes. A further concern shared by trainees and trainers was the erosion of the traditional value base of general practice and the need for more discourse on core professional values in general practice training. This is reflected in the current debate about the meaning of generalism and how it should be reflected in a reductionist age.23
Box 3 summarises key roles for future GPs that were derived from analysis of the 100 words from GPs and patients. The consultation has been seen as the core of general practice for over 40 years.7 Unsurprisingly, the ability to deliver patient-centred care in the future, through high-quality consultations, was repeatedly endorsed by GPs and patients at the discussion day and in the 100-word statements.
‘GPs must retain their sensitivity to patients' narratives; that advocacy for patients will save general practice.’ (GP)
The ability to consult well was also implicit in the responses of patients to the question ‘What do you value from your GP?’; these included:
‘Being treated as an individual.’
‘I value my GP's attention and time.’
‘Gives me confidence to manage things myself.’
‘Listens to suggestions I put forward regarding treatment for my condition’.
Qualities identified as required of a GP in the future included the following:
General practice is a discipline in which the doctor-patient relationship is the active ingredient of almost everything that is achieved.24 In such a relationship, it is clear that the personal qualities of the doctor are complementary to clinical skills. The qualities identified by the learning journeys are closely reflected in the descriptors of medical professionalism in a recent Royal College of Physicians (London) report.25
The purpose in undertaking this project was to ask how, in the midst of frequent bureaucratic shifts and increasing service pressures, the essence of general practice can be explored and an attempt can be made to define it — those characteristics that are at its heart and central to its purpose and ethos, and that, therefore, should be of principal concern in shaping its future. It became obvious early in the course of this project that it was neither possible nor desirable to reach a one-sentence definition of the essence of general practice. However, through the learning journey process, roles were identified as well as personal qualities that are vital to high-quality general practice in the future. These personal qualities reflect the need for humanism, which is consistently identified as necessary for the future of general practice but often either marginalised or underexamined.26,27 In a rapidly changing international, national, and local context, the key activity of GPs must remain the clinical encounter. The consultation — and how and where it is provided — must be informed by research and evidence,26 guided by wisdom, and underpinned by values. The current tendency to reject the need for a broadly humanistic approach in favour of a narrow biomedical one28 needs to be challenged by both the academic and the working GP community, by exploring these aspects of general practice using the tools of narrative, anthropology, sociology, and philosophy.7,26,29 As well as this, in an ageing population with multiple morbidity becoming the norm rather than the exception, whole-system changes will be required to ensure that patients with complex physical, emotional, and social needs benefit from the holistic, continuous, and coordinated care required to improve individuals' and communities' health.
Although the direction of NHS policy appears to suggest that many functions of the GP can be performed by other professionals, including pharmacists and nurses, GPs are still uniquely trained, motivated, and situated, geographically, historically, and culturally to take forward this task in the 21st century. GPs of the future will require leadership skills, political vision, and a clear sense of purpose if they are to steer a primary care-led NHS towards achieving the worthy goals of its founders. The key advantages of general practice continuing to be central to the future development of primary care are summarised in Box 4.
The learning journeys and discussion day have been learning experiences for the authors of this paper as well as for all the participants. Based on the learning journeys, the analysis above, and subsequent reflections, three stark challenges face the discipline and threaten its future survival. The first challenge is to ensure that the blend of qualities, roles, and features that constitute the essence of general practice, as described above, remains the active ingredient of primary care and survives ‘new arrangements’ (in which GPs are likely to be required to work differently with almost everyone). The second challenge is to make this happen across the board and not just in leading-edge practices. The third, and the most important challenge, is the challenge of leadership by GPs rather than of GPs: in university departments, deaneries, professional bodies, and NHS management structures. This will be essential to maintain direction and momentum in the face of unsympathetic, antagonistic, and uncomprehending external forces.32 In the words of one GP participant, ‘disengagement is a terrible prospect’. Will future GPs grasp the leadership nettle or leave this natural niche unfilled?
We would like to thank all doctors and patients who contributed 100 word summaries and who attended and contributed thoughtfully to the learning journeys and discussion day. The ‘100-word’ concept, central to the process, was that of Professor Julian Tudor Hart. We would also like to thank Professor David Blaney, Dr Carey Lunan, Dr David Reilly, and Sharon Weiner-Ogilvie for ideas and analysis. Professors Kenneth Boyd and John Howie, and Drs Graham Buckley and Mike Porter contributed to the initial stages of the project. Ruth Wallace, Laura Kelleher, and Leanne Brown of RCGP (Scotland) have provided invaluable organisational support and advice.
Figure 1 describes the elements and stages of the learning journey process which was used to help stimulate thinking and develop insights. Working together as a team in a learning journey to make sense of a difficult challenge provides powerful traction for further understanding and action. A learning journey begins with some colleagues agreeing to explore an important issue or challenge together. Having agreed on the issue to explore, they make site visits which might help to illuminate aspects of this challenge. Having made the visits they then reframe the challenge according to what they have learned. Figure 1 illustrates the stages in the process from issue identification, through site visits and reflection, to reframing the issue and associated policy and practice. The learning journey provides a focus for rapid learning and insight development. Site visits provide the basis of common focused experience around issues and concerns of interest — in this case the essence of general practice.
We live in a context of increasing complexity, rapid change, and uncertainty. While change is a common feature of life through the ages, there comes a time, every 250 years or so, when society and its institutions, values, memes, and mores undergo a more fundamental shift, a transformation. There is now a significant literature to suggest that we are currently living through such a time. In this soup of change, long-held ideas and beliefs do not work as well as they once did. While some of the current thinking, theories, and actions work well for straightforward problems, they work less well for rapidly emerging challenges and looming issues, such as shifting patterns of health and disease, climate change, persistent inequality, and governance. This raises the question of how to be effective in current times, when forms of organisation and practice designed for a world that no longer exists are less effective.
Successful learning journeys provide a way to approach this complexity. They usually include an experienced facilitator and support team. They include a range of field trips, usually, but not always, focused around a key theme or issue of interest, and are challenging to perception, mental models, and perspectives. Learning journeys are a good way to explore this present complexity to gain strategic insight about how to move forward on an issue. They help to unpack complexity and uncertainty through engagement. They surface and make explicit the assumptions that an individual or group holds. They can help to explore worldviews and mindsets in relation to important challenges from the outside in, by looking at the driving forces in the world at large, in the sector of operation, the organisation, and individual. This links learning journeys to the field of scenario planning.33 In particular learning journeys:
In the work on the essence of general practice, the following types of organisations were initially visited:
The above two visits were planned to pilot the method for the essence of general practice group — would it prove a convivial method for us as a group? Would it provide useful insights? What could we learn from a pilot about how we might use the method subsequently? Participants were members of the essence steering group and the Director of Integrated Care at Glasgow Homeopathic Hospital. These two organisations were chosen because they were very different from each other and, in many respects, from general practice. In fact, the visits proved useful in highlighting that the issues that were explored in the essence of general practice group were very similar to concerns and issues being addressed in other walks of life.
This journey was focused on educators and trainees in general practice in South-East Deanery, NHS Education Scotland. All trainers were emailed (educational supervisors) and trainees in the deanery and they were asked to participate in a project designed to help ‘develop an understanding of their work and the core values which inform and guide both the work and the practitioners’. Three trainees, four trainers, a researcher, and a facilitator took part.
This learning journey included sessions with:
These visits were chosen to be diverse in their activities, approach to life, and aims and goals. Ostensibly different from general practice in organisation, motive, purpose, and intention, these visits raised a number of challenges to ideas about general practice; for example, what is unique about general practice? Discussion of these insights in subsequent debrief session, as well as detailed notes taken by two authors led to the key lessons in Box 2, which are also reflected in Boxes 3 and 4.
Following the first learning journey, a discussion day for GPs was organised in Scotland under the title ‘General practice: what sort of job; what sort of person?’. A ‘world café conversation’ model was used,18 designed to enable creative and wide-ranging discussion. Members of the steering group selected individuals to invite who would offer a wide variety of ideas and views on the subject. GPs were purposively selected from a variety of backgrounds — remote and rural, inner city, academic, as well as GP directors of education, trainers, and trainees. Prominent UK thinkers in general practice were included, as well as a poet and a psychologist.
In all, 88 people were invited, and 40 attended, in addition to the steering group.
To stimulate discussion, some prominent UK GPs were commissioned to write 100 words, approximately, on general practice. The following idea was that of Professor Julian Tudor Hart:
‘What I suggest is that you circulate a request to perhaps 10 to 20 GPs known for both original thought and action sustained through their professional lives, each to contribute their view of the most critical choices facing future students and educators creating GPs of the future, in not more than 100 words. These could be printed on cards including the authors' names (I think this would prompt more vigorous discussion), with a full set given to each participant. Ideally, they should get these before they arrive for the discussion so that they don't have to waste too much time reading them, can select what each thinks are the most important alternatives, and possibly develop their own 100-word statements.’
The steering group and Professor Tudor Hart asked 27 doctors to write 100 words. Seventeen replied; one has since asked that his contribution not be included. An example is:
The most critical choices facing future students and educators creating GPs of the future
Three key choices for educators
These were sent to participants in advance, and also displayed prominently in the room on the day for reference.
The setting, a restaurant in a theatre in Glasgow, was chosen deliberately not to be associated with medicine, to encourage original thinking and free association of ideas.
The day started with short (3–4 minutes) personal reflections on general practice from four individuals (three of the authors and Dr Euan Patterson), summarised in the RCGP learning tools,18 and was facilitated by Andrew Lyon from the International Future Forum. An initial plenary discussion was followed by ‘café conversations’ — small groups set up to explore issues more deeply. Group members were rotated twice during the day, which finished with a plenary session. Data were gathered in several ways. The plenary sessions were digitally recorded. Participants wrote ideas on paper tablecloths as they developed, and these were analysed and summarised. These were combined into a single report circulated to participants.
Subsequently we asked the RCGP Scotland Patient Participation Group to write 100-word statements on the related questions:
The group comprises five lay members and two GPs. (The GPs wrote on ‘What do I value about being a GP?’ and ‘What do I see as the unique role of a GP?’.)
An example is given below, from a lay member: What do you value from your GP?
‘I value the fact that, when talking to my GP, he is open and truthful, empathetic, and will listen to suggestions that I put forward regarding treatment for my condition. It is teamwork.’
‘What I value: time; sympathetic and caring (but also humour); gives me confidence to manage things myself; never makes me feel I am wasting his time; I have confidence in him because he never pretends to know everything and will stop to check things (for example, dosages) if unsure. I respect him for that. A good listener, unhurried. Continuity of care so we have built up a relationship.’
‘I value most of all the time my GP gives me, the level of understanding and interest around my health and life issues, also other qualities such as, patience, an alternative perspective, support, encouragement, and trust.’
‘My GP takes time to explain things to me, draws diagrams, etcetera. He is prepared to accept what I say about adverse reactions to prescriptions and change them if necessary.’
The sections ‘Learning from the journey’ and ‘Defining the essence of general practice: the journey continues’ summarise key findings from the learning journeys, the 100 words, and the discussion day.
We are grateful to RCGP (Scotland) and NHS Education Scotland for financial support
The authors have stated that there are none
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