Intended for healthcare professionals


Divided we fall: the commodification of primary medical care

BMJ 2018; 360 doi: (Published 22 February 2018) Cite this as: BMJ 2018;360:k787
  1. Bruce Guthrie, professor of primary care medicine1,
  2. Stewart W Mercer, professor of primary care research2
  1. 1Population Health Sciences Division, University of Dundee, Dundee, UK
  2. 2Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
  1. Correspondence to: B Guthrie b.guthrie{at}

Allowing segmentation of general practice is a risky strategy with largely unknown consequences

Healthcare is intrinsically complex, and all healthcare systems have struggled to find an appropriate balance between generalism and specialism.1 Managing coordination and transitions across boundaries between specialist services is also a growing challenge in a world of multimorbidity.1 General practice is the core element of generalist provision since hospital doctors have become increasingly specialist, but recent developments risk fragmenting generalist primary medical care.

The Nuffield Trust recently published a report examining the implications of the trend towards “segmenting” populations to provide different types of care for people with different needs.2 Concerns about this are neither new nor unique to the UK. Julian Tudor Hart’s expression of the inverse care law in the 1970s (that the quality of medical care is usually worse for those with higher need) was underpinned by concerns that commodification of care would undermine universality and holistic generalist care.3 Similarly, in the US there has been considerable recent debate about the “Amazon-ization” of primary care, with …

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