Musical musings: GPs should be the orchestra

David Mummery is a GP in West London and a research fellow at the Department of Primary Care and Public Health, Imperial College London

In this new and ever-changing era in primary care, it is quite commonly said that the GP role has changed and that we are now the ‘conductors’ of a great primary care ‘orchestra’ of other allied healthcare professionals working within primary care. GPs in this system should: co-ordinate MDTs; only see more ‘complicated’ patients; sit in endless non patient-facing meetings, such as primary care network (PCN) or clinical commissioning group (CCG) meetings and work more in the managerial and financial aspects of general practice: in essence be predominantly non-patient-facing as a sort of ‘primary care consultant’. In this system GPs do not see the more simple – but possibly crucial – patient presentations, there is less chance and opportunity to make long-lasting, trust-based relationships with patients, spanning many years, and there will not be the endless clinical variety of people and problems that makes the role of the GP so important and fulfilling.

…it is quite commonly said that the GP role has changed and that we are now the ‘conductors’ of a great primary care ‘orchestra’..

Of course the GP has always in a way been a ‘conductor’ between different hospital specialists, co-ordinating treatments and providing holistic care, but this is highly relevant in the context of PCNs where there are lots of new types of allied health professionals needing supervision and training by GPs that take GPs away from their own clinical care of patients. In my experience a lot of work is actually generated (possibly unnecessarily) by the new roles, that it would have been simpler and more efficient just to see a GP in the first place : that is what I mean by GPs ‘being the orchestra.’ Obviously an orchestra is a broad and very imperfect analogy, but I use it to argue that the clinical care and seeing patients should primarily be done by GPs (providing there are enough of them) and that the new roles, despite some merits do seem to cause a lot of confusion and duplication of work. Of course other members of the primary care teams like practice nurses are hugely essential, but they may have well defined roles that do not need constant GP supervision; they can handle and look after their own caseload, whereas it seems that physicians assistants, for example can’t and therefore need constant GP reviews.

It seems therefore that the unique role of the GP is rapidly being broken up into its constituent parts, through the PCN system and is disappearing before our very eyes, both figuratively and literally, with the number of GPs in inexorable decline. It is easy to see, and it is well documented, especially recently, why and how this is happening.

I would argue that for general practice to remain as perhaps the greatest of all the medical professions, that this is not the way forward. general practice has to remain a clinically focussed, predominantly patient-facing profession, with face to face care the bedrock of practice, but of course embracing technology and remote working as and when appropriate.

The PCN paradox is that the PCN system seems to be actually workload generating: allied healthcare professionals who understandably are not confident or trained in the broader aspects of primary care commonly refer patients back to the GP for the final and ongoing decisions regarding patient care and management. This, plus remote working can make care more inefficient and cause confusion and duplication of efforts and appointments. Medical conditions that are self-limiting illnesses are highlighted as medical problems needing investigation and ‘treatment’ and over-diagnosis and over-medicalisation is rife. Is it a co-incidence that the current severe GP workload crisis has happened since the introduction of the PCN system?

This wonderful variety of clinical work has to be communicated to medical students and young doctors as a truly fulfilling career and vocation.

For general practice to thrive and prosper as a profession in the future, the clinical aspects, and seeing patients, whether ‘simple’ or ‘complicated’ have to be core. This wonderful variety of clinical work has to be communicated to medical students and young doctors as a truly fulfilling career and vocation. Consequently the current general practice contract and conditions have to drastically improve to reflect this including: capped workload; comprehensive occupational health for all GPs; flat GP hierarchies within primary care; improvement of GP buildings and facilities and well as many others to make General Practice as really compelling and exciting profession for a young doctor to become a member of.

Therefore for general practice not to be obliterated as the best career choice and vocation that a young medic can choose, GPs have to be the ‘primary care orchestra’ and not just conductors of the orchestra.

Deputy Editor’s note: Responses and debate are welcome, including ideas that make use of a music metaphor. For example: is chamber music or jazz a better analogy for a medical speciality that sometimes leads, and sometimes contributes in the background as the rhythm and tempo of human need dictate?


Featured photo by Manuel Nägeli on Unsplash

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