Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: A consultant model of general practice

BMJ 2024; 385 doi: https://doi.org/10.1136/bmj.q821 (Published 09 April 2024) Cite this as: BMJ 2024;385:q821
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}phc.ox.ac.uk
    Follow Helen on X @HelenRSalisbury

In interviews and appraisals, doctors of all varieties are often asked to provide evidence of their “teamwork.” Doctors are used to working in teams, especially in hospital specialties where a consultant routinely heads a hierarchy of junior doctors who (as well as the multidisciplinary team) will all be involved in caring for each inpatient.

This stands in contrast to the much flatter structure of traditional general practice, where most of the clinical staff are fully qualified GPs looking after their own patients. They share day-to-day clinical work with other members of the team—such as nurses and, more recently, pharmacists and physiotherapists—who each bring their specialist skills, but most of the central task of consulting, diagnosing, and formulating management plans is done by GPs. As surgeries are important places for training the next generation of doctors, some GPs also teach medical students and supervise specialist trainees, but these training roles are far fewer in number than in hospitals.

Medical care in hospitals is often described as consultant led, whereas in general practice it’s GP delivered. However, there are plans to replace this model of GP care with a system where much of the care is delivered by other, less highly trained staff. This is demonstrated in proposals set out by NHS England in the Fuller stocktake report and in the development of same day access hubs, which are planned by a number of integrated care boards.12 In these models GPs spend much of their time supervising others—advanced nurse practitioners, paramedics, physician associates—who have most of the face-to-face contact with patients presenting acutely.

Some GPs welcome this move and others see it as inevitable, but from my perspective it’s neither desirable nor inevitable. It may be cheap in the short term but not in the longer term, as it increases investigations and referrals.3 It’s also likely to result in a worse patient experience and less safe care.4 There’s no shortage of young doctors wanting to be GPs, just a lack of funding for training places, and there are now unemployed GPs because practices lack the resources to pay them.56 Thus this change in model seems driven by ideology and short term financial arguments rather than necessity.

Do current GPs and those entering training want to be consultants in primary care, supervising a team of non-medically qualified healthcare staff? Or do they aspire to traditional general practice, holding a personal list and offering expert medical care and continuity to patients and families? GPs should be discussing this question as a profession, feeding back their conclusions to their professional bodies and political masters. For my part, my expertise is in consultation, diagnosis, and medical management, and I want to spend most of my time using these skills and passing them on to my trainees.

If this new role is the future we’re planning for GPs, we should warn trainees of this and adjust the GP training scheme to reflect this altered reality. We should also ask if this model is what patients want. Patients do need better access to general practice, but this should be achieved by training and employing the doctors who want to join us, rather than recruiting to other roles that offer fragmented, anonymous, and less expert care.

Footnotes

References