Kieran Sweeney Prize winner 2025: The GP model for delivery of Primary Care is outdated for the society in 2025

Ben Hoban is a GP in Exeter

It is difficult for a doctor to imagine primary medical care without GPs, and yet for many patients in the UK today, that is their experience: the majority of appointments in general practice are now not with general practitioners, but with non-medical clinicians, many appointed through the Additional Roles Reimbursement Scheme.¹ Outside the surgery too, community pharmacies, walk-in centres, and NHS 111 all act as additional first points of contact with the health service, and out-of-hours providers are responsible for patients over a greater part of any week than their registered GP. Services which were introduced to support general practice now seem on the point of replacing it. Within the consultation, Artificial Intelligence software is regularly being used to facilitate data entry, but it requires little imagination to see its role growing along similar lines. Have we reached a tipping point, beyond which technology and the diversification of the primary care workforce will make general practice redundant?

Modern medicine developed in dissecting rooms, laboratories, and hospitals as the scientific exploration of the human body and the diseases that affect it.² As such, it is based on the intellectual principles of objectivity, reductionism and inductive reasoning. We are professionally committed to the idea that a whole can be understood by the disinterested examination of its parts, and that by examining a sufficient number of similar parts, we can draw conclusions that apply to them generally. It is easy to see how doctors became lab-coated experts in different organs, standing over cases of this-or-that condition tucked up anonymously on the appropriate ward. Within this paradigm, the individual with their distinctive story is largely irrelevant; their personal concerns are put away, folded up with the clothes in which they arrived. Whoever is responsible for the patient – and it is never the patient themselves – need not know the person at all, but must rather know about people in general and the thousand ways in which their bodies malfunction. Their job is to look beyond the individual, to apply a consistent process leading to a reproducible outcome.

All doctors are therefore philosophically the heirs of Andreas Vesalius, Ignaz Semmelweis, and Rosalind Franklin, regardless of where they work. Hospital doctors have remained truer to those roots than GPs, however, and the difference is what is really at stake here. Historically, GPs are descended not just from scientists, but also from apothecaries and grocers.³ We work locally among our patients, who mostly walk into our surgeries fully dressed to make an appointment when they decide to, rather than being removed from their everyday lives by ambulance, supine and blanketed, when chance dictates. During a consultation, we sit opposite each other, and it is the patient’s agenda that sets the tone and defines the success or failure of whatever happens next. Process and outcome matter, but so do purpose and meaning. From this perspective, what goes on in general practice is really the antithesis of the biomedical model. We recognise the value of the relationship between doctor and patient not just as a nicety, but as the place where uncertainty is carried, sense made, and decisions agreed; we engage as much with a subjective, personal, and at times idiosyncratic understanding of the problem as with the cool, rational, scientific one.⁴ We have the privilege of applying the large and unwieldy apparatus of healthcare to the unique needs of the fellow-human in front of us, but it is not always a good fit.

It is this lack of fit that demonstrates both the limits of medicine and the need for distinctive general practice. While it is important to be able to identify and treat disease, this is true for most people only insofar as disease gets in the way of other things which matter more: work, family, and everything else that makes up the edifice of life rather than its foundation. Conversely, many patients suffer from problems that do not have a clearly defined cause, or whose causes fall outside the usual understanding of disease, but which still have a profound impact on their health. A strictly medical approach exposes these patients to various kinds of iatrogenic harm without necessarily having much to offer beyond bland reassurances. Within the general practice model, by contrast, we recognise that the purpose of healthcare is not simply to diagnose and treat disease, but to enable everyday life.⁵ GPs are therefore uniquely equipped to take into account the people as well as the pathology. We have the freedom both to hold back the medical machine when it is unnecessary, and to offer help and care even when medicine provides no easy answers.⁶

Consequently, general practice acts as a gate-keeper between people and medicine as much as between primary and secondary care. We refer patients partly to escalate their management, but also to reduce the associated uncertainty or risk to a level that can safely be held in general practice; they are subsequently discharged not just because they are better, but also because below a certain degree of acuity, their needs are better met closer to home and by someone who knows them. We need a balanced healthcare system that can operate in both scientific and interpersonal modes, the left hand working with the right. Without general practice, primary care would simply be a community-based form of hospital medicine. We may work more naturally with one hand than the other, but would we really exchange a balanced pair of hands for either two right or two left ones?

This is where the proposed “three shifts” towards digitally enabled, community-based preventive care run into difficulties.⁷ We use technology to grease the wheels of even the most trivial undertaking, and it is hardly controversial that we should apply it to healthcare. There is a danger, though, that the way we go about this may ultimately distort the process we are trying to facilitate. It is convenient to order pizza through an application on our phone, but relying exclusively on the app will tend to limit our choice of pizza, encourage us to eat more pizza than is good for us, and make it harder for those without reliable internet access to eat pizza at all.⁸ Similarly, while community-based care clearly ought to be the norm for most conditions, the language of a shift from hospital to community takes hospital practice as normative and implies that it simply needs to be moved to a different venue. It would be more accurate to say that a properly resourced community sector would have less need for hospitals to begin with. Finally, the perennial assertion that prevention is better than cure hides a clutter of assumptions and values behind a proverb’s smooth façade. It is certainly better not to be ill if one can help it, but the experience of many in the Covid-19 pandemic was that some of the measures taken to prevent viral transmission were much, much worse. It may cost less to treat the entire population over fifty with statins than to deal with the acute and chronic needs of those with heart disease, but does that necessarily make it the best approach? Where health follows a social gradient, shouldn’t prevention also mean improving the circumstances of the most vulnerable in society, or at least improving their access to primary healthcare in the first place?⁹

It has become too easy to overlook these distinctions, to consider simplistically things that are by their nature more complex. We are providing more and more appointments, and yet somehow, patients are still not getting what they need. Taking time to listen feels like an extravagance, and personal continuity of care is rationed rather than assumed. It should be clear that the problem with primary care is not just a lack of capacity, but also of balance.

It may seem self-serving to invoke the spirit of expert-generalist, whole-person care when many patients struggle to access the basics, and yet there is a big difference between what is basic and what is fundamental.¹⁰ Adequately functioning general practice is not a luxury product that we cannot afford, but an everyday essential, without which we are forced to rely on less appropriate and ultimately more costly alternatives. It is struggling to deliver primary care not because it is poorly suited to it, but because it has been prevented from operating in a way that draws on its natural strengths.

In answer to the question, then: yes, the GP model has become outdated, but only through having had one hand tied behind its back by false notions of progress; the answer is not to abandon it, but to set it free. It is high time that we rediscovered the benefits of a more balanced kind of healthcare, rooted in both science and humanity, whose goals are not defined solely in terms of disease, but also of life lived well. We should aspire to offer more than simply medicine, not simply more. General practice can do this if we allow it to.

Deputy Editor’s note:

The Kieran Sweeney Prize 

Professor Kieran Sweeney was a GP in Exeter who died in 2009 of mesothelioma, at the age of 58.  He applied ideas from philosophy, the arts, mathematics, business and social sciences to the care of his patients and the process of healthcare. He was an accomplished medical writer. The Tamar Faculty of the RCGP is to honour his memory again with a national prize for the best original piece submitted by a practicing GP in answer to the question posed.

The Article 

The article must be previously unpublished and have been written solely by the entrant.  Ideas from disciplines outside medicine such as the arts, business, philosophy, literature, or political and social science will be especially welcome. The piece should be written in prose at a level that an interested member of the public will understand, under the title “The GP model for delivery of Primary Care is outdated for the society in 2025”

Details of past prizes and entries may be seen here:

1. https://bjgplife.com/kieran-sweeney-prize-2021/
2. https://bjgplife.com/what-does-the-future-hold-for-the-relationship-between-a-patient-and-their-gp-in-the-uk/
3. https://bjgplife.com/kieran-sweeney-prize-winner-what-does-the-future-hold-for-the-relationship-between-a-patient-and-their-gp-in-the-uk/

References

1. Appointments in General Practice, February 2025, NHS Digital, digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/february-2025
2. Roy Porter, The Greatest Benefit to Mankind: a Medical History of Humanity, Harper Collins, 1997
3. U. Bloor, The rise of the general practitioner in the nineteenth century, Journal of the Royal College of General Practitioners, 1978, 28, 288-291
4. Royal College of General Practitioners. Definition of a GP. Consensus statement September 2023. rcgp.org.uk/about
5. Michael Dixon and Kieran Sweeney, The Human Effect in Medicine: Theory, Research and Practice, Michael Dixon and Kieran Sweeney, Radcliffe, 2000
6. Road to recovery: the government’s 2025 mandate to NHS England, Published 30 January 2025 www.gov.uk/government/publications/road-to-recovery-the-governments-2025-mandate-to-nhs-england/road-to-recovery-the-governments-2025-mandate-to-nhs-england [accessed 17/7/2-25]
7. David Misselbrook, Aristotle, Hume and the goals of medicine, Journal of Evaluation in Clinical Practice, 2015, doi:10.1111/jep.12371
8. Sarah Burns, Could access initiatives worsen inequality? BJGP Life, 3^rd March 2025, www.bjgplife.com/could-access-initiatives-worsen-inequality/ [accessed 17/7/2-25]
9. Michael Marmot, The Health Gap: The Challenge of an Unequal World, Bloomsbury, 2015
10. Joanne Reeve, Medical Generalism, Now! Reclaiming the Knowledge Work of Modern Practice, CRC Press, 2023

Featured image by Kaitlyn Baker on Unsplash