Introduction

Most people with chronic conditions such as diabetes, congestive heart failure, asthma, and depression are managed in primary care. NHS consultants have traditionally confined their role to patients who are referred to outpatient clinics by their general practitioners. Such patients usually have the most severe and complex problems. Effective care teams for chronic illness must be able to cross practice or organisational boundaries,1 but the current organisational structure of the NHS does not provide many incentives to develop such linkages. General practitioners refer patients they cannot manage and hospitals are funded on the basis of referrals. Time spent on joint work with primary care is not accounted for. To ensure that all patients get the best treatment, the role of consultants needs to change so that their specialist knowledge is more available to everyone dealing with chronic disease.

Changing roles

In recent years nurses in the NHS have taken on a larger role in managing patients with chronic disease. Specialist nurses work alongside both general practitioners and consultants to assist in managing people with complex problems in both hospital and community settings, and practice nurses now act as case managers to patients with conditions such as diabetes in primary care. However, there has been little integration of primary and specialist care through shared information systems and clinical protocols, such as that seen in US health maintenance organisations.2

Many US managed care programmes use specialists as part of the primary care team

Credit: AP PHOTO/MONTY DAVIS

During a research fellowship spent in a health maintenance organisation,3 I had the opportunity to observe and discuss how the role of the specialist might differ from the traditional role. On the basis of my experience I believe that changing the role of consultants requires two key conceptual shifts.

Population perspective

The first shift required is …