Views And Reviews No Holds Barred

Margaret McCartney: Let’s ditch the stuff we don’t need to do

BMJ 2017; 358 doi: (Published 18 July 2017) Cite this as: BMJ 2017;358:j3457
  1. Margaret McCartney, general practitioner
  1. Glasgow
  1. margaret{at}

My fellow columnist David Oliver recently made an excellent challenge to GPs: what’s the consensus on how the future of general practice should look?1 To be honest, I fear the worst: that we may not have one.

GPs are a hugely diverse group of doctors. We have a four nation NHS, each evolving its own priorities, its own challenges (some needless and self made), and different GP contracts, reflecting philosophical and political differences. It’s a big, messy, uncontrolled trial without ethics committee oversight.

GPs have no consistent employment practices and, despite model contracts, these are all negotiable. GPs can be salaried employees, freelance locums, or partners. They can work in, or own, small corner shop businesses or large practice chains. Some salaried GPs work 10 sessions a week for £50 000 or less a year, and a few partners own and manage chains of surgeries and earn over £250 000.2 Some GPs rent their buildings from private companies, others from a health board; and others own property worth more than their business.

Some GPs do nothing but deliver clinical care, which I still consider (unfashionably) to be the most important, and hardest, of the jobs we do. Others teach, research, commission, lecture, work in the media or medical politics, manage organisations, or appraise or train other GPs.

Some GPs have specialist interests. Some look after nursing homes or provide rural trauma care. Others do only out-of-hours emergency work from on-call centres. And private companies aggressively advertise to GPs to leave the NHS, to do easier work for better money on the end of a video call.

Two things, especially, scare me about the future of general practice. The first is financial conflicts of interest. More than a third of GPs on the boards of clinical commissioning groups in England have financial interests in for-profit private providers “beyond their general practice.”3 This will make financial sense for a few very wealthy partners, but having a small number of GP partners contracting work to other GPs on a lower salary destabilises the infrastructure of primary care and undermines its sustainability.

The second is the impact of “new models of care,” where people can consult other professionals—a nurse or a physician assistant—or receive home visits from such allied healthcare professionals, rather than seeing a GP. These are enthusiastically rolled out in many areas, but substantial uncertainties surround the long term impact of such changes, as well as a lack of interrogation into their potential harms.

Two things, especially, scare me about the future of general practice: financial conflicts of interest and new models of care

We should certainly be asking questions. One is what level of training people need in carrying out a particular task. Another is what evidence we have when deciding on the appropriate level of training for that task. But why are we passing on the most difficult, challenging stuff that we’ve been trained for years to do—that of managing undifferentiated symptoms—when so many other things don’t need to be done by GPs, if at all?

We’ve missed a trick. The workforce revolution should begin by freeing GPs from all of the things we don’t need to do, including bureaucratic contract nonsense, much form filling, and sorting out yet more prescriptions that are “not in stock.” This would give us more room to get back to caring for patients and more doctors who might see general practice as a pleasure, not a strain.

Spending money to identify the work that eats up minutes and has collectively pushed us over the edge of sustainability is urgently required. We need to keep our core work close to our hearts. A consensus that clinical work in general practice is a good place to spend your career would be a start.



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