Mary McCarthy: The value of generalists

In 2019, the European Union of general practitioners/family doctors issued a statement entitled “The Value of GPs.” Drawing on evidence from published papers, it pointed out that family doctors were the robust base of any cost-effective healthcare system. Family doctors provide person-centred, holistic care to their patients, embedding themselves in their local community so that they remain aware of their patients’ socio-economic factors, of psychological pressures, and of family influences, in order to help their patients’ manage their problems. They provide personalised medicine in its purest form. general practitioners/family doctors are the bedrock of safe healthcare.

So, if you were faced with the task of constructing a health service for a new and recently discovered population, how would you go about it? Would you look at the evidence of what has worked well in other countries or situations? Would you examine those areas where health outcomes were good? Would you read the papers of Barbara Starfield and consider the evidence that spending money at base level or up-stream, is more amply rewarded in terms of health outcomes than spending money on very visible shiny buildings with expensive equipment? 

Generalists are good value for money. General Practitioners are of course the ultimate generalists, dealing with all diseases at all ages, but also included in this cost-effective group are geriatricians, paediatricians, and general physicians, although this last category is getting rarer every year in the UK.

If other examples of cost-effective healthcare systems are looked at it becomes obvious that spending money on preventing disease is better than spending money on treating it and good public health is important—a fact that has been glaringly obvious during the covid-19 pandemic. Making healthcare, social care, and education, the priorities for a nation, brings into being the possibility of a healthier population at a reasonable financial cost.

The WHO Alma Ata Declaration of 1978 recognised the need to orientate healthcare towards general practice and care in the community. In the years since, an extensive body of international research has shown that it is the continuity of care and patient-centred approach specific to general practice/family medicine that is associated with better health outcomes, equity of access, reduced inequalities in health, more appropriate utilisation of services, and of long term effectiveness.

In the UK at present, despite the pandemic over the past 18 months, healthcare is not a priority. It receives 9% of GDP, a figure that compares poorly with France and Germany. Of this restricted health budget, general practice gets about 9%. Despite this poor investment, general practice is the first medical contact for 90% of medical problems, including covid-19 infections. GPs deal with 80% of those problems, which include chronic disease, acute undifferentiated illnesses, mental health, care of the dying, care of babies and children, and the numerous socio-economic problems that land in a GP’s day, from relationship difficulties, to inadequate housing, or benefit problems.

General practitioners do a difficult, complex, and tiring job, dealing with 40-50 patients a day, with bureaucracy increasing both the workload and the hours worked. Most general practice days in the UK are 12-14 hours long. As a comparison, in much of Europe, GP lists are around 1000 patients, GP hours are eight hours a day and patient contacts are around 25 patients a day. There are fewer GPs per 100,000 population in the UK than in comparable European countries. A commodity that is scarce would normally be valued. It seems odd, therefore, that GPs, the ultimate generalists, seem not to be appreciated or valued in society. The only way to have a cost-effective healthcare system, and better health outcomes for a population, is to employ more generalists.

The evidence is there, we just need to apply it to what, at present, is a struggling general practice workforce. The NHS will not survive without robust and sustainable general practice. Now is surely the time to devote funds, resources, and energy into supporting such a valuable commodity. 

Mary McCarthy, Vice President UEMO (European Union of General Practitioners), BMA Council.

Competing interests: none declared.