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Views And Reviews Acute Perspective

David Oliver: Towards a GP consensus on the future of UK general practice

BMJ 2017; 357 doi: (Published 20 June 2017) Cite this as: BMJ 2017;357:j2949

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Re: David Oliver: Towards a GP consensus on the future of UK general practice

David’s hypotheses is that there is more that divides us (GPs) than unites us and he challenges us to find a consensus. This is long overdue, but there are fundamental problems that cannot be overcome very easily. Underlying our differences lie ontological and epistemic uncertainties. Put simply, there is no consensus on what a GP is, or what GPs do. These differences of form and function are not just philosophical, but are actual differences in how we practice and moral differences in what we ought to be and ought to do.

Many GPs chose to leave institutional life in hospitals because they value independence and autonomy more than their secondary and tertiary care peers. I have no evidence but I’d guess that doctors who had a happier time in boarding school are over-represented in not-so-dissimilar hospital institutions. GPs are the historical descendants of 19th century community apothecaries who worked in the communities they served. There were only allowed to join the medical profession – who boarded themselves away from communities, in hospitals - after a long and acrimonious battle. Suspicions, snobbery and differences remain even though this is far beyond the living memory of any doctor working today. My experience of 17 years in General Practice, which followed 4 years of hospital specialty posts and a stint overseas, is that I have become, and am becoming, something increasingly far removed from a hospital doctor. I practice social medicine, or as I have recently described it, ‘Poverty medicine’. My job, as I see it, is to help patients make sense of suffering and it is through making sense of suffering that everything else follows. I first grasped that this was what I was trying to do when I read Iona Heath’s 1995 Mystery of General Practice shortly in 2001. This short book does more than any other to try and define what a GP is and does.

She also warns that there are social processes in which patients are being transformed into consumers, healthcare into a commodity, and divisions between health and social care are being defined according to who is responsible for payment and delivery. These were even better articulated in Julian Tudor Hart’s, The Political Economy of Healthcare and are still being debated by everyone from the Kings Fund to Keep Our NHS Public today. The transformation is being driven by factors ranging from GP contracts to neoliberal individualism.

These changes have led to increasingly divergent philosophies of being and practice among GPs. Some see themselves as medical practitioners working in community clinics, with biomedical boundaries imposed by both resources and philosophy. Others see ourselves as social practitioners and community advocates, with boundaries imposed by bureaucrats with no understanding of patient needs. There are similar divides between those that see healthcare as a profit-oriented business and those who see healthcare as a human right that is fundamentally undermined by profit motives. Some business-oriented GPs may be fully committed to social medicine, but there are others who believe that the Inverse Care Law will ultimately lead to resources being distributed away from areas of greatest need the more that profitability drives investment. These ontological differences about what we are shape our moral differences about what we ought to be and what we ought to do, and therein lie some of the fundamental problems.

There is a reciprocity between making sense of suffering with the patients that I see every day and my identity as a GP. The one shapes the other. And as a trainer for the last two years, I have seen this transformation in my trainees. I think that we need to pay more attention to what GPs are and what we do. I suspect that most younger GPs will want to be in a Salaried Post so that they can concentrate on clinical activities like care, quality improvement and service development without the partnership pressures of finance, HR and contracts. And I believe, with some, possibly naïve optimism, that the next generation will be even more committed to social medicine than my own.

Competing interests: No competing interests

21 June 2017
Jonathon P Tomlinson
GP Partner Trainer