The future of the primary medical workforce
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5006 (Published 22 August 2011) Cite this as: BMJ 2011;343:d5006
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Stephen Trumble's editorial was spot on with its analysis of the
future of health care. However he did not touch on the single most
important issue regarding GPs taking on a bigger role within the health
system. Currently GPs work within small structures that simply cannot
afford to fund their time to undertake this work. If they stop their
regular patient centred role they stop being GPs and will no longer bring
that experience and understanding to the table.
My partners were incredibly understanding when I was involved in The Next
Stage Review (as were my patients) but good will is not enough. Whilst
academic doctors and consultants can rely on back up from their
institutions and will personally receive merit awards for this work, GPs
are unable to access any of this support. This is the most fundamental
reason why GPs are still invisible to the NHS above PCT structures in the
NHS.
If the system is serious about GPs taking on leadership roles they must
adequately support them to remain GPs and carry out this vital work.
Competing interests: I have been a GP for 20 yrs and was involved as a clinical champion for South Central Strategic Health Authority during Lord Darzi's Next Stage Review
Being confronted daily with an obviously aging population, longer
life expectancies, ever advancing medical care, budget constraints and
G.P. commissioning, it would be very difficult for any medical student in
the U.K. not to be aware of the growing importance of providing healthcare
in the community. Despite reluctance in medical graduates to commit to
general practice as early as other specialities, 1 it becomes increasingly
popular as they progress through postgraduate training. 2
There is a continuing effort in the U.K. to ensure that medical
training, both undergraduate and postgraduate, is conducted in a manner
that fulfills the needs of our health system. 3 The General Medical
Council oversees undergraduate education and ensures that medical schools
deliver clinical experience in primary care in the same structured and
planned manner as they do with hospital specialties. 4 From personal
experience, medical students now spend at least 20% of clinical time in
the community - predominantly with G.P.s but also in other primary care
settings such as pharmacies, care homes and working with community nurses.
Moreover, experience of general practice and community care is not limited
to clinical attachments as much is learnt from G.P.s through formal
teaching sessions. 5
With Foundation Programme applications looming, it has also become
clear that our exposure to primary care will continue into our
postgraduate training. Modernising Medical Careers has identified that
traditional boundaries between primary and secondary care are diminishing
and care pathways are becoming more integrated. 6 This is reflected in
changes being made to general postgraduate training and G.P. training
itself.
The past five years have left me under no allusions of the current
and future importance of delivering healthcare in the community, making a
career in primary care attractive, attainable and feeling less isolated
from secondary care than perhaps it has done in the past.
References:
1. Goldacre MJ, Laxton L, Harrison EM, Richards JMJ, Lambert TW,
Parks RW. Early career choices and successful career progression in
surgery in the UK: prospective cohort studies. BMC Surg 2010;10:32.
2. Jones L, Fisher T. Workforce trends in general practice in the UK:
results from a longitudinal study of doctors' careers. Br J Gen Pract
2006; 56(523): 134-136.
3. Goldacre M. Planning the United Kingdom's medical workforce. BMJ
1998;316:1846-1847.
4. General Medical Council: Tomorrow's Doctors London: GMC; 2009.
5. Thistlethwaite JE, Kidd MR, Hudson JH. General practice: a leading
provider of medical student education in the 21st century? MJA 2007;
187(2).
6. Tooke J. Aspiring to Excellence: Final Report of the Independent
Inquiry into Modernising Medical Careers. MMC Inquiry 2008 Available from
URL: www.mmcinquiry.org.uk
Competing interests: No competing interests
In line with reported data in developed countries (USA, Australia,
New Zealand, Canada and the United Kingdom), a developing country as
Argentina provides a quite similar reality corroborating that the world
primary medical care is not a favoured career choice for specialty
training and practice, yet. Some factors have been opportunely pointed out
for explaining this situation in our country. A scarce conscience in the
collective imagery and in the mass media - exceeding its increasing
presence in the last years -, a fragmented health care system which
conspires against a primary care-oriented one and the decision on
specialization already made by students when entering to our medical
school may be among the most relevant reasons. Furthermore, the
paradigmatic pressure received from specialized teachers during the
clinical years becomes an additional factor to be considered 1, 2.
To sum up, at present primary care physicians remain still being more
a remarkable curricular purpose than an effective postgraduate actuality
in Argentina.
References
1. D'Ottavio AE, Miguel JC Postgraduate specialization of Argentinian
medical students in the 1960s and 1990s. Acad. Med 74: 10: 1029-1030, 1998
2. D'Ottavio AE. Family Medicine Education in Argentina (Letter to
the Editor). Acad. Med. 83: 1124-1124, 2008
Competing interests: No competing interests
Having just (yesterday!) retired from 27 years in General Practice in
the UK, I read this paper from a slightly different viewpoint - that of
"What has made me leave general practice?"
To be a GP within the UK previously allowed a practitioner a number
of roles and responsibilities - not least the ability to build up a
"jigsaw" of a patient's complex history comprising interactions between
disease, coping strategies, concerns, family, environment and media
intervention to name but a few. Using his ability artistically to
interpret the science of medicine the GP could balance provision of care
against the ability to improve the patient's wellbeing. Alongside this
role was the then "fun" of health economics coupled with the autonomy of
running a business and developing health campaigns and activities to liven
up the day to day consultation rate.
So what has changed in recent times?
The three significant changes that have occurred in recent years and
which have speeded my retirement from practice at the tender age of 55
have been
1: The loss of independent thought and consequential inability
to develop medical care for the future as a result of the continued
pressure of guidelines and protocols being thrust upon us all with the
consequential concern of litigation if there should be any deviation from
guidance
2: The lack of confidence of new entrants to General Practice
who cannot see any patient without ordering a rack of blood tests and
their inability to look at a patient holistically using basic science and
physiology to determine disease process
3: The constant downgrading of
medical care within the UK as GPs are forced to save money by referring to
each other instead of secondary care specialists... GPs do not see the
range of conditions with the research and specialist knowledge skills of
consultants and hence cannot feasibly provide an appropriate second
opinion in the majority of cases
Education and learning in medicine is by exposure to conditions and
to the patient. In General Practice we used to be able to promote
independence and family care - now all we can promote is the need to
practitioners to be conversant in committee-speak and financial
accountability. No wonder fewer doctors want to take up primary care - the
personal awards are no longer those of job satisfaction or feeling that
you have made a little happiness or relief come into your patient's life.
Now while financial reward is probably adequate the lack of support from
those managing primary care makes it an unhappy place to be.
Competing interests: No competing interests
GPs are quite up to date with management of various cardio
respiratory conditions (eg CCF, angina, COPD), Diabetes and Arthritis even
though hospital based specialties exist for these conditions. But with
cancer, although GPs are quite aware of cancer 'red signals', many GPs are
not quite up to date with cancer treatment and subsequent follow up since
most of this activity, so far, has been almost exclusively a hospital
based activity. This is likely to change in the near future and there is
an urgent need for GPs to get up to date with follow up protocol of
various cancers.
With the introduction of Payment-by-Results (PbR: www.dh.gov.uk), the
follow-up visits are being scrutinised by commissioners. I understand in
some regions an unrealistic 'new to follow-up ratio' of 1:5 has been
mooted for cancer patients. There is likely to be opposition from patients
and scepticism from clinicians about the practicalities of this proposal.
But in the era of evidence based medicine and cost effective health care,
it is going to be hard to justify hospital follow-up of healthy patients
for many years without evidence of benefit. In fact, the evidence-base
supporting intensive hospital follow-up visits and investigations is weak
for most adult cancers.
Quite often patients and family find it difficult to accept that
intensive monitoring and frequent follow up scans do not prevent relapse.
Early diagnosis of a secondary cancer i.e. after cancer has spread does
not improve prognosis. This because most stage 4 cancers are incurable and
chemotherapy is only palliative for many patients. Hence symptom led
investigations are quite the norm for many cancers and GP led follow up
can be safely done, with referral to hospital at symptomatic stage only.
A lot of follow up studies suggest that intensive follow up
investigations and possibly hospital follow up are not beneficial and in
fact futile for many adult cancers.
In an ovarian cancer randomised study, no survival benefit was noted
for early diagnosis of cancer relapse using serum CA125. In fact, early
diagnosis of relapse, at an asymptomatic stage, impaired the quality of
life of patients. (1)
An Italian breast cancer follow-up study randomly assigned patients
to intensive follow up scans or symptom led follow up. The study found
that neither survival nor health-related quality of life was better with
intensive follow up of cancer and hence suggested that routine use of
these tests should be discouraged. (2)
A Cochrane Metanalysis of breast cancer follow up found no benefit
for intensive surveillance to detect cancer relapse at asymptomatic stage.
(''regular physical examinations and yearly mammography alone are as
effective as more intensive approaches''). The analysis also found that GP
led follow up is as effective. (3)
A large German follow up study of bladder cancer patients found no
benefit for early detection of recurrence at an asymptomatic stage and
hence advocated symptom guided follow-up examinations. (4).
In prostate cancer patients treated by radiotherapy, a Royal Marsden
study found that digital rectal examination (DRE) failed to detect any
local recurrences in the absence of a rising PSA. The authors questioned
the standard model of follow-up after radiotherapy for prostate cancer,
and suggested that alternatives, such as telephone clinics, should be
considered. (5).
In patients with locally advanced lung cancer, frequent cross-
sectional imaging was not found to improve survival after combined
modality therapy (6).
In contrast, with Colon cancer, a Cochrane Metanalysis found that
intensive follow up is associated with an improved all-cause survival. But
there was little information available about the harms and costs
associated with intensive follow up. Moreover some of the suggested tests
such as CEA and liver imaging could be organised by GPs rather than by
hospital based clinicians.(7)
Testicular cancers, along with childhood cancers and haematological
cancers are other possible malignancies which would benefit from intensive
hospital follow up.
But for considerable majority of patients with highly prevalent
cancers (breast, prostate, ovary, Lung), GP led follow up could be safely
done.
References:
1. Rustin GJ, van der Burg ME, Griffin CL, Guthrie D, Lamont A,
Jayson GC, Kristensen G, Mediola C, Coens C, Qian W, Parmar MK, Swart AM;
MRC OV05; EORTC 55955 investigators. Early versus delayed treatment of
relapsed ovarian cancer (MRC OV05/EORTC 55955): a randomised trial.
Lancet. 2010 Oct 2;376(9747):1155-63.
2. Liberati A. The GIVIO trial on the impact of follow-up care on
survival and quality of life in breast cancer patients. Interdisciplinary
Group for Cancer Care Evaluation. Ann Oncol. 1995;6 Suppl 2:41-6.
3. Rojas MPMP, Telaro E, Moschetti I, Coe L, Fossati R, Liberati A,
Rosselli MDT. Follow-up strategies for women treated for early breast
cancer. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.:
CD001768. DOI: 10.1002/14651858.CD001768.pub2
4. Volkmer BG, Kuefer R, Bartsch GC Jr, Gust K, Hautmann RE.
Oncological followup after radical cystectomy for bladder cancer-is there
any benefit?J Urol. 2009 Apr;181(4):1587-93.
5. Doneux A, Parker CC, Norman A, Eeles R, Howich A, Huddart R,
Dearnaley D. The utility of digital rectal examination after radical
radiotherapy for prostate cancer. CLINICAL ONCOLOGY, 2005: 17 (3). pp. 172
-173.
6. Benamore R, Shepherd FA, Leighl N, Pintilie M, Patel M, Feld R,
Herman S. Does intensive follow-up alter outcome in patients with advanced
lung cancer?J Thorac Oncol. 2007 Apr;2(4):273-81.
7. Jeffery M, Hickey BE, Hider PN. Follow-up strategies for patients
treated for non-metastatic colorectal cancer. Cochrane Database of
Systematic Reviews 2007, Issue 1. Art. No.: CD002200. DOI:
10.1002/14651858.CD002200.pub2
Competing interests: No competing interests
Let clinicians, of all disciplines, practice their profession and brace yourself for the deluge of applications.
There has never been a golden age of anything, least of all general
practice. The multi dimensional and dynamic nature of health in the
community is such that the best plan is to anticipate endless change and
populate the workforce with well-rounded professionals of all relevant
disciplines, who operate in locality based, autonomous, multi-disciplinary
teams and who, crucially, can instantly adapt, extemporise and act
effectively in response to any exigency in a manner best suited to their
locality and population.
Local care for local people by local services - if you like.
Optimal care is achieved when patient and professionals, being known
to each other and on all good terms, act together to solve problems with
the help of ubiquitous secondary and tertiary services. Health cannot be
'done' to patients by statute, fiat, exhortation, bombast, casuistry,
spreadsheet, business plan, strangers, automata or technocrats.
The NHS was established to relieve the fear of illness, injury,
suffering and death. It was never intended to provide all care, for all
people, all of the time. Both statements being as relevant to day as then.
The scope of provision needs to be defined - as appears to be being
proposed in India.
Guidlelines are obsolete before publication, over complex and
therefore merely ammunition for the litigious. The thundering avalanche of
text that cascades through the NHS at all levels is actively harmful and
almost invariably both otiose and impenetrable. CCing an email or
promulgating managerialist blah is not communication, it is creating an
impediment to work.
Let primary care professionals of all disiplines exercise their hard
won clinical skills autonomously for 75% of the working week in direct
patient contact. 15% of the week being for CPD and 10% only being for
adminstrative duties.
Nobody I know trained to be a manager. We all trained to be doctors.
If clinicians are permitted to perform their proper tasks, quality,
output and morale would rocket upwards. Recruitment and retention would be
no problem at all.
Steve Ford
Competing interests: Retired from general practice in 2008 at the age of 55 in order to register the withdrawal of my consent from what has been and is being done to the NHS. Stood in 2010 as an Independent in the general election - my first boss after qualification was Dr. Richard Taylor who was twice elected as MP for Wyre Forest - got 4.5% of the votes cast.