Rapid responses are electronic comments to the editor. They enable our users
to debate issues raised in articles published on bmj.com. A rapid response
is first posted online. If you need the URL (web address) of an individual
response, simply click on the response headline and copy the URL from the
browser window. A proportion of responses will, after editing, be published
online and in the print journal as letters, which are indexed in PubMed.
Rapid responses are not indexed in PubMed and they are not journal articles.
The BMJ reserves the right to remove responses which are being
wilfully misrepresented as published articles or when it is brought to our
attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not
including references and author details. We will no longer post responses
that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dr Mathew’s commendable article advocating ‘major reforms that bring our profession together’ not surprisingly falls short of providing details of what those reforms might look like.
From my perspective as a retired GP, who arguably, practised during the heyday of General Practice, it is worth noting the significant changes that have occurred over the last 30-40 years and their consequences.
In the ‘old days’, as many of my colleagues will recall, the GP terms of service were called the ‘John Wayne’ contract: “A GP’s gotta do what a GP’s gotta do.” No QoF, no targets, little bureaucracy.
Practices were run, to variable degrees of effectiveness, by, mainly male, full timers who either provided, or were responsible for providing 24/7 care.
On that basis General Practice was, quite rightly, regarded as the ‘gatekeeper’ of the NHS, not just for elective care but also for urgent care, protecting our ‘specialist’ colleagues and the hospital system from being overrun with less consequential problems.
Chronic disease management was largely the remit of the doctors themselves; the management of diabetes or COPD being intermingled with sick children, mental health problems and psychosocial issues, during the course of a routine surgery offering the grateful patients all of a 5 minute consultation.
Of particular note was ‘shared management’ with hospital maternity clinics of antenatal care which, although usually not particularly clinically taxing, did provide the basis of long term relationships with young families which persisted over decades.
It is probably also worth remembering that this, clearly now outmoded, system of practice formed the basis of the 1990’s flirtation with GP Fundholding, which, had Tony Blair not killed it off in 1997, was well on the way to forming a clinically based integrated health and care system which, thirty years later, is still merely aspirational as various political leaders, with varying degrees of knowledge and understanding, reorganise interminably and at great expense.
So … It could be argued that General Practice is no longer an effective NHS ‘gatekeeper’, continuity of care is largely illusory and GPs themselves have delegated long term condition management to specialist nursing colleague whilst paramedics are increasingly providing acute care and home visiting. The question that this poses is, in John Wayne speak, “What’s a GP gonna do?” And here we come back to Dr. Mathew’s challenge.
The profession should try and sort out the problem itself before the Secretary of State imposes his own solutions. We know that the latter is a recipe for disaster and confrontation, with doctors risking being on the wrong side of public opinion.
There must be a recognition, within the profession, that whilst many practices are doing a fantastic job, despite workforce challenges, Covid constraints etc. etc, some are, for whatever reason, neither well enough organised, or sufficiently aware of the perception of the poor service they are providing, to head off the political storm being unleashed overhead.
There also needs to be an honest debate within General Practice about its place in the ‘new world’. Recruitment issues are not going to be solved for many years, either in Primary Care or in the broader health and social care system, and the skills available to manage the demands of the ‘sick’ public are no longer the sole remit of doctors.
In parts of the country attempts are being made to solve these issues by functional, rather than organisational, integration. The Primary Care Network concept, in its infancy in some areas, provides a basis for change with opportunities for professional business management and broader skill, therefore recruitment, opportunities.
The concept of Primary Care as an ‘out-of-hospital’ system fully incorporating the skills of paramedics, generic and specialist nurses, pharmacists, physiotherapists, social workers, public health experts and many others surely has to be the way forward, as is being demonstrated, though patchily, by some ‘system leaders’.
GPs do not have to regard themselves solely as ‘generalists’, indeed many have specialist skills in a whole variety of clinical and non-clinical roles which should be nurtured.
Underpinning this must be a properly funded and integrated IT system, again apparent in some parts of the country but sadly lacking in others.
It is the professions’ leaders’ role to stimulate this ‘levelling up’ of out of hospital care; to incentive not punish; to stimulate and share good practice; to demonstrate effectiveness and patient satisfaction and, above all, to cost the changes required and ensure a fair slice of the NHS cake for the whole sector of non-Acute care.
Dear Editor
I am a salaried Gp, having been a partner in the past. My personal experience is in keeping with what the author has stated. Each role has specific challenges and there are factors which means negotiations need to be carried out to ensure a fair agreement and to avoid exploitation. There is definitely a reduction is number of FTE GP’s due to various factors such as, appraisals, tax changes, work load, press and public perceptions, all playing a part in the morale of the profession, it is at rock bottom. I am concerned about the future of general practice.
Re: Rammya Mathew: Making general practice a sustainable career again
Dear Sir,
Dr Mathew’s commendable article advocating ‘major reforms that bring our profession together’ not surprisingly falls short of providing details of what those reforms might look like.
From my perspective as a retired GP, who arguably, practised during the heyday of General Practice, it is worth noting the significant changes that have occurred over the last 30-40 years and their consequences.
In the ‘old days’, as many of my colleagues will recall, the GP terms of service were called the ‘John Wayne’ contract: “A GP’s gotta do what a GP’s gotta do.” No QoF, no targets, little bureaucracy.
Practices were run, to variable degrees of effectiveness, by, mainly male, full timers who either provided, or were responsible for providing 24/7 care.
On that basis General Practice was, quite rightly, regarded as the ‘gatekeeper’ of the NHS, not just for elective care but also for urgent care, protecting our ‘specialist’ colleagues and the hospital system from being overrun with less consequential problems.
Chronic disease management was largely the remit of the doctors themselves; the management of diabetes or COPD being intermingled with sick children, mental health problems and psychosocial issues, during the course of a routine surgery offering the grateful patients all of a 5 minute consultation.
Of particular note was ‘shared management’ with hospital maternity clinics of antenatal care which, although usually not particularly clinically taxing, did provide the basis of long term relationships with young families which persisted over decades.
It is probably also worth remembering that this, clearly now outmoded, system of practice formed the basis of the 1990’s flirtation with GP Fundholding, which, had Tony Blair not killed it off in 1997, was well on the way to forming a clinically based integrated health and care system which, thirty years later, is still merely aspirational as various political leaders, with varying degrees of knowledge and understanding, reorganise interminably and at great expense.
So … It could be argued that General Practice is no longer an effective NHS ‘gatekeeper’, continuity of care is largely illusory and GPs themselves have delegated long term condition management to specialist nursing colleague whilst paramedics are increasingly providing acute care and home visiting. The question that this poses is, in John Wayne speak, “What’s a GP gonna do?” And here we come back to Dr. Mathew’s challenge.
The profession should try and sort out the problem itself before the Secretary of State imposes his own solutions. We know that the latter is a recipe for disaster and confrontation, with doctors risking being on the wrong side of public opinion.
There must be a recognition, within the profession, that whilst many practices are doing a fantastic job, despite workforce challenges, Covid constraints etc. etc, some are, for whatever reason, neither well enough organised, or sufficiently aware of the perception of the poor service they are providing, to head off the political storm being unleashed overhead.
There also needs to be an honest debate within General Practice about its place in the ‘new world’. Recruitment issues are not going to be solved for many years, either in Primary Care or in the broader health and social care system, and the skills available to manage the demands of the ‘sick’ public are no longer the sole remit of doctors.
In parts of the country attempts are being made to solve these issues by functional, rather than organisational, integration. The Primary Care Network concept, in its infancy in some areas, provides a basis for change with opportunities for professional business management and broader skill, therefore recruitment, opportunities.
The concept of Primary Care as an ‘out-of-hospital’ system fully incorporating the skills of paramedics, generic and specialist nurses, pharmacists, physiotherapists, social workers, public health experts and many others surely has to be the way forward, as is being demonstrated, though patchily, by some ‘system leaders’.
GPs do not have to regard themselves solely as ‘generalists’, indeed many have specialist skills in a whole variety of clinical and non-clinical roles which should be nurtured.
Underpinning this must be a properly funded and integrated IT system, again apparent in some parts of the country but sadly lacking in others.
It is the professions’ leaders’ role to stimulate this ‘levelling up’ of out of hospital care; to incentive not punish; to stimulate and share good practice; to demonstrate effectiveness and patient satisfaction and, above all, to cost the changes required and ensure a fair slice of the NHS cake for the whole sector of non-Acute care.
John Hughes FRCGP
Competing interests: No competing interests