What's special about medical generalism? The RCGP's response to the independent Commission on Generalism

Following the publication of the independent Commission on Generalism,¹ the Royal College of General Practitioners (RCGP) undertook an extensive consultation with its members and published its follow-up report in June 2012.² GPs were very positive about seeing the basis of their discipline from a new perspective, and were keen to have the value and skills of medical generalists more strongly supported across the modern NHS. This editorial summarises some of the key issues from the consultation, and asks ‘What is the essence of medical generalism, and where is it most needed in our health system?’.

DEFINING GENERALISM

The Commission's definition of medical generalism runs to several paragraphs, noting that:

‘The essential quality is that the generalist sees health and ill-health in the context of people's wider lives, recognising and accepting wide variation in the way those lives are lived, and in the context of the whole person.’¹

The RCGP follow-up report extends this to define medical generalism as:

‘… an approach to the delivery of health care that routinely applies a broad and holistic perspective to the patient's problems.’²

Key to this definition of generalism is the concept of interpretive medicine:^3,4 a ‘biographical’ perspective, taken by professionals who are experts in dealing with people which, from the outset, is focused on individuals and how they deal with the world. It involves:

‘… establishing a rapport that can be therapeutic, in the sense of developing shared insights. It is enabling and developmental, in that it has the potential to move individuals on from where they are, whether this is in terms of understanding/knowledge, emotional capabilities, or in making decisions about undergoing investigations and treatment options.’²

Whether a practitioner is a true generalist or not depends on their training, their attitudes, their scope of practice, and frequently their work setting. There is a difference between being a generalist and using generalist skills. A doctor who sees only patients with a specific set of clinical problems (for example, a family planning specialist) may have lost some skills in the diagnosis and management of other types of problems. However, they can act as a generalist when they note nervousness in a female patient, for example, and expand their remit to investigate undeclared risks, such as sexual abuse, domestic violence, sexually transmitted disease, or depression.

CHALLENGES AND PRIORITIES FOR GPs

The Commission posed several questions about: why GPs value continuity and person-centred care, but no longer provided any named practice contact for their patient population over a 24-hour period; why those in nursing homes with the most complex dependency needs often lacked a generalist leading their care; and why patient feedback was often underused.

The Commission also advocated for better specialist–generalist communication, and for more medical training to be generalist in its core approaches, so that those taking up specialist appointments appreciate the skills of generalists, and can use them when required.

Responders to the RCGP consultation accepted these ideas, and were also clear that new models had to be found that avoid the ‘single-handed 24-hour shift’.

As well as case mix and breadth of approach to the consultation, many GPs involved in the consultation agreed that relational continuity over time5 is a key constituent of best generalist practice. This enables cumulative knowledge and understanding to be used effectively, whereas multiple providers addressing single issues in a complex picture would at best be inefficient, and at worst be unaware of important clinical and personal issues for patients.

Giving the ‘right care, at the right time, in the right place’ was seen as a core feature of generalist practice, and practices need to evaluate actively how to balance the value of expanded skill mix and expertise in their services against risks to access and continuity. Suggestions included an appropriate use of a named GP for most consultations and reviews, supported by a good team with an appropriate skill mix, and someone who could be accessed out of hours for necessary practice input.

Medical generalists need:

’… effective training in excellent clinical method for generalist practice; retention of those skills through appropriate breadth of case mix and continuing professional development (CPD); access to best near patient and ambulatory diagnostic testing; and enough time with patients to manage their needs and preferences appropriately.’²

The College agrees with patient and medical responders that 10 minutes is now very short to combine a patient-centred approach to information gathering, do a proper examination, and make an effective shared management plan.^6,7

The role of the GP is also to lead the team and develop services: while this has always been true for running a practice, the potential of GPs to act as clinical leaders across practice boundaries has become clearer recently. Being a GP in the UK requires: ‘… leadership skills, political vision, and a clear sense of purpose’.⁸

While being generalists at the heart of the healthcare system was a challenge welcomed by many GPs taking part in the RCGP consultation, there was concern about capacity, and a firm view that non-medical colleagues could complement, but not substitute for, GP skills. The report suggest that more services need medical generalists in the frontline of managing patients with multiple comorbidities, and also in the initial diagnostic phase; this may be an expanded role for GPs, and a focus for service commissioning. There was also a recognition that more research is needed to evaluate the complex issues around the appropriate use and impact of generalist care.

ENHANCING THE STATUS OF GENERALISM

There are many other gems from GPs and others who made thoughtful input to the RCGP consultation, and its impact is already being felt. There is a cross-College commitment to taking a number of proposals forward, and we challenge other medical specialities to consider their own need to train and retain generalists within their own disciplinary context. The Royal College of Physicians is already convening its own debate on what generalism means to hospital-based physicians.

The recent recommendation by the Medical Programme Board for enhanced training for GP trainees will give a real opportunity to embed generalist competencies in those gaining MRCGP, and to enhance the status of primary care medical generalists. And the RCGP was proud to be able to tell the Commissioners that it is already leading on issues such as nursing home care,⁹ integration of care,¹⁰ and continuity.

GPs (or ‘family medicine practitioners’ in other countries) are the quintessential generalists, because they routinely see people across all types of health and medical problems, at all stages of the lifecycle, and for any stage of a problem from health promotion to the management of severe ill health and frailty. Primary care teams in the UK provide generalist services free at the point of use to their patients who can develop relationships with staff over time and get help with health care regardless of their age, need, or problems. The GP remains the front door and the community face of the NHS, and principles of practice are still based on two key concepts: holistic and patient-centred care. This is true generalism, which has a set of core skills, principles, and an appropriate ethos of generalist medical care.

History can change things for the better or worse. It is essential that the essence of generalism is articulated, valued, and preserved. Medical generalism is about guiding patients through complexity: it is about kinder, safer, more efficient care, and it is about helping people:

‘… to understand and live with their illnesses and disabilities, to integrate them into their life narratives, and within the confines of the options available to them to make this a narrative of flourishing.’ (P Toon, personal communication, 2012).

GPs are experts in whole person medicine; that is the essence of our discipline, and its future.

Acknowledgements and competing interests

The work on the RCGP Commission on Generalism has been supported by funding from the Health Foundation. Amanda Howe was lead officer for this work, with Dr Maureen Baker, and supported by the policy team, in particular, Paul de Ponte and Jonathan Ware. Amanda Howe led the writing of the report, and authored this editorial, which draws on the Report to which many members contributed ideas and views.