In Defence of 'Generalist Healthcare'

In an era of moderate panic about our NHS, and pessimism about the future of General Practice, I’m going to make a pitch that there has never been a more important time for ‘Generalist Healthcare’ to predominate. I see Generalist Healthcare as being able to blend the medical with the non-medical, consider real life wider determinants of health alongside scientific insights. It uses careful and highly refined expertise to enable shared decisions considering medical, social and emotional factors; assessing people’s individual capabilities alongside their life context. Generalist Healthcare recognises when medical care like treating blood pressure with pills is less important, even in prevention terms, than sorting out things like relationships, housing or self-esteem.

?

I say this to contrast with the Specialist predominated era that I’ve practiced in all my career. In response to a ‘health problem’ doctors are trained to make a medical diagnosis. Anxiety, Angina, Type 2 Diabetes, ?Irritable Bowel, Migraine, Asthma……they each sit within a specialist area, mental health, cardiology, endocrinology, gastroenterology, neurology, respiratory. At the head of each '-ology' sits a team of specialist consultants. They tend to dictate best treatment in their area.

?

The predominating culture is that these medical experts know best. They lead teaching and education, that filters down to general practice through early career training in hospitals, or ongoing ‘update’ training.? They sit at the end of referral pathways, a long wait often adding to their perceived importance.

?

The role we need health care to deliver has changed. 50 years ago, we mostly needed a reactive medical system responding to acute illness like infections or injuries. It was appropriate for care to be delivered in short appointments, and perhaps appropriate to be led by specialist supervision.

?

Now, we are living longer and indulging in lifestyles that don’t suit our biology. The reasons are complex, a mix of both successes and failures, behaviours and environment. But the result is a surge or people living with more complex mixes of long-term conditions. The ask of health care has shifted to match the change in our population. Within this modern setting Generalist Healthcare is now most likely to shepard the best health outcomes. It is important both in terms of managing people living with chronic illnesses, but also in helping us get upstream and preventing further long-term deterioration.

?

Within a specialist led paradigm sits a deep knowledge of the latest science and medical treatment, be that drugs, operations or therapies…….mostly interventions we do to people.? There is no doubt that they have their place, but I think for current health care to be dominated by specialist approaches is like Formula One dictating the design of a family campervan!

?

I don’t want to undervalue my learned colleagues in specialist settings, for whom I have the greatest respect. I admire their focus and depth of knowledge, and with the most complicated conditions in their area, or in an emergency their interventions can literally be lifesaving. But in most situations these days, I don’t think it is appropriate for their detailed knowledge to trump the Generalist paradigm. We need to recognise the overarching importance of a carefully balanced medical and non-medical approach in a chronic disease managing system.

?

I’ve always seen our role as a Primary Care Network (PCN) as offering a non-medical wrap around to support and complement the more medical approaches delivered in practices. General Practice has always been the place where health meets social, and the continuity of relationship as a ‘family doctor’ has supported a holistic approach. However, it is still led by doctors, who are medically trained, and mindful of their accountability to make a medical diagnosis, prescribe, and refer to specialists. I observe that as the BNF thickens, the NICE guidance volumes increase, and medical litigation looms larger, General Practice has learnt to occupy an ‘accepted space’ defined by public and professional traditions of a disease oriented, specialists dictated approach.

?

I have relished the role that Primary Care Networks have offered. There has been a bravery in the NHS giving permission (in fact mandating) introduction of new roles that widen the scope of the primary care team and allow us to set up a viable non-medical wrap around.

I know it is often threatening to established practice, especially at a time when we are seeing GP numbers dropping and practice finances under strain, but it is a shift Primary Care must make if we are going to serve the purpose most needed of us. I really hope that this truly Generalist approach in Neighbourhoods is given time to keep on exploring, like a camper van, discovering the 'sights' of great care.

?

?