Domhnall MacAuley: The future of general practice….is private

Domhnall MacauleyWhat will happen in general practice…now that we have so many part time portfolio doctors, practices where the focus is on performance related income, increasing delegation to practice nurses and nurse practitioners, and patients often seen by someone who has little knowledge of their past medical history? Out of hours care, for at least 8 of 24 hours each weekday, weekends, and bank holidays is provided by contract doctors. Midwives provide maternity care, health visitors define their own role in routine paediatric care, palliative care is offered by specialist units, and a number of hospital clinics provide community outreach. You may see someone different each time you go to the surgery. The traditional GP providing personal, primary, and continuing care will soon be extinct.

When you and I develop our chronic illnesses we may tire of recounting our medical history to endless different professionals who focus on segregated parts of our health and know nothing of our past. If we decide we’d like to see the same doctor who knows us and our family, where would we look? And, how much would we be prepared to pay for this type of care?

If I were a young GP, who believed in the traditional values of general practice—of personal, primary, and continuing care, accessible 24 hours a day, I would invest heavily in premises and open up in private general practice. Primary care, as we remember it, is unlikely to be available in the future. People know the value of good care and as the middle aged, middle class, become disillusioned with UK primary care, they will weigh up how much they are prepared to pay for a real GP. In the US they call it concierge medicine—private general practice to us. Two tier inequitable healthcare is coming but no politician or professional organisation dares to say it publicly.

Domhnall MacAuley is primary care editor, BMJ.

  • Charlotte Paddison

    Domhnall MacAuley is right: the traditional GP providing personal, primary, and continuing care is becoming a rare species indeed. But the future of primary care does not need to be entirely bleak. How might we contribute to a more positive future for primary care in the UK? Perhaps we could start by:

    1. Redefining the ‘new professionalism’

    There is much that is positive about the ‘new professionalism’ within general practice. Some might ask: are ‘old values’ still relevant to the practice of modern medicine? Perhaps the answer is a qualified ‘yes’. Personal responsibility for patients has, historically, been a defining feature of general practice in the UK. But over time we have seen the insidious erosion of personal responsibility for patients in primary care. Redefining the ‘new professionalism’ to better recognise the value of personal responsibility for patients might help to (re)promote personal, continuing care in general practice.

    2. Thinking critically about how we define ‘quality’ in health care

    When it comes to managing quality, there are some things that we find easier to measure – and therefore easier to attach financial incentives to – such as access. Other dimensions of quality are less easily quantified. For example, the co-ordination of care. Over time, this difference in ease of measurement may have an important influence on how we come to define ‘quality’ in health care. Perhaps the growing fragmentation evident in UK primary care stems, in part, from our collective failure to incentivise the things we find difficult to quantify. The net result? Our definition of what quality is, may become unnecessarily shaped by what can be easily measured.

    What I find very useful about Dr MacAuley’s blog, is that it energises us to strive to create an alternative vision – one that contributes to a more positive future for primary care in the UK.

    Camp3@medschl.cam.ac.uk

    * Expanded blog on same topic available at: Cambridge Centre for Health Services Research http://www.cchsr.iph.cam.ac.uk/560

  • Dr Fred Kavalier

    If you become a concierge doc in a boutique practice, the only patients you will see are the rich and the worried well. It’s not what I went into medicine for…