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Views And Reviews Wounded Healer

Clare Gerada: From clap to slap—general practice in crisis

BMJ 2021; 374 doi: (Published 14 September 2021) Cite this as: BMJ 2021;374:n2224
  1. Clare Gerada, GP partner
  1. Hurley Group, London
  1. clare.gerada{at}
    Follow Clare on Twitter: @ClareGerada

A journalist sat with me in my clinic recently to witness the nuts and bolts of a GP’s day.1 This was a first for me. Watching me at work involved none of the razzamatazz so loved by the media: no high vis jackets or equipment constantly beeping, no crowds of staff in hospital scrubs rushing to save the life of a patient.

My work has none of these (other than the grunts and groans when the IT system fails again). Instead, it involves sifting slowly and expertly through the huge burden of undifferentiated distress that patients present with—day in, day out. General practice delivers 1.22 million appointments every weekday. My job is to understand how our patients’ fragments of illness fit together to form the complex jigsaw that makes up a human being.

Strong primary care provides the best way of coping with the complexity of life in the 21st century and the globalisation of unhealthy lifestyles. Without GPs the NHS would collapse under the pressure of work and rising costs, and patients would be lost in a sea of endless choices and dilemmas. Yet, despite decades of research showing the benefit of GPs in improving the nation’s health, reducing costs, and delivering equitable, cost effective care,2 general practice is at risk of falling over. This will be to the detriment of us all: specialists, generalists, and most importantly our patients.

Workload far exceeds our capacity to respond to demand, leading to a spiral of discontent among patients and staff. For GPs this has profound consequences, not just on their mental health (suicide, depression) but also their physical health (cancer, cardiovascular disease) and family life (divorce). Around the country, those of us who remain in clinical practice are working even harder: trying, yet often failing, to meet the needs of patients. Instead of being offered support and resources, we’re criticised for being idle, for referring patients to specialists inappropriately, and for not caring. In the space of months, we’ve gone from “clapping for carers” to slapping down the profession.

Investing more in primary care is not about denying the value of hospital specialists. Far from it. Specialists and GPs, while sometimes perceived as opposites, are inextricably dependent on each other’s skills. Generalists and specialists bring different and complementary skills. Specialists aim to reduce uncertainty, explore possibility, and marginalise error; the generalist aims to accept uncertainty, explore probability, and marginalise danger.3

Political leaders must now focus on why demand is exceeding resources. Responding to this is their responsibility. This is not just about money (although that would help) but about investing more thought into why we’ve got into this state and how such a valued and valuable workforce has become so denigrated. We need the resources—workforce, IT systems, estates, and mental space—to innovate our way out of this mess.4 For the sake of our patients, this is now mission critical.



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