The specialist/generalist debate

The recent publication of the report from the Commission on Generalism, established by the Health Foundation in partnership with the Royal College of General Practitioners, stirred some considerable interested in the media. So why did the Foundation establish a commission on a subject which to some might seem a little esoteric?

Let me explain by asking you the following question: if you were designing a health system from scratch, would you staff it with people who have highly specialised skills who are brilliant at doing a small number of things extremely well, or with people who can do a wider range of things in less depth?

Of course this is an overly simplistic question because any health system requires both sorts of people but, nevertheless, the question is an important one. If the aim is to deliver as high quality care as possible within the constraints of the available resources, what is the right balance between a specialist and a generalist orientation for your workforce?

For many decades the trend has been in favour of increasing specialisation, particularly in the medical profession, and exploring the history of this phenomenon helps to explain why.

More than 150 years ago, each of the groups of practitioners who came together to form the modern medical profession in the UK – the apothecaries, the physicians and the barber-surgeons – were all essentially generalists, though the highly educated physicians thought of themselves as rather more ‘special’ than others. But over the years, the desire to be an expert in a defined area of practice led the physicians first, then the surgeons, to become increasingly specialised in diseases or parts of the body. With the demise of the hospital-based general physician and general surgeon over the last couple of decades, an increasingly clear division has emerged between community-based generalists and hospital-based specialists.

Anyone who has had reason to see a specialist will appreciate the advantages of in-depth knowledge and skills in narrow areas of practice. This has led some commentators to claim that the future of medicine lies in even greater specialisation, that the days of the generalist are numbered.

But too great a focus on specialisation can bring its own problems. Specialisation encourages doctors to look at the parts rather than the whole and this can result in a less person-centred approach to the delivery of care. It can also lead to the medicalisation of complex problems and to increased risks associated with greater interventions.

Planning and utilising a specialised workforce can be complicated. And in the current environment, the economics cannot be ignored. It is no accident that countries with a larger proportion of specialists, like the USA or Sweden (where there are ten times as many specialists as generalists), spend considerably more of their GDP on health than countries like The Netherlands or the UK (where there are an equal number of specialists and generalists). Indeed, there is strong evidence from the seminal work of Barbara Starfield (‘Contribution of Primary Care to Health Systems and Health’) that health systems with a generalist orientation consistently achieve better outcomes at lower costs.

So, the benefits of generalism need to be better understood and actively encouraged, particularly where the benefit is high quality care for patients and more efficient use of resources. That is why the Health Foundation established the Commission and why, working with the RCGP, we are encouraging an active discussion on the subject.

The Commission has come out unequivocally in favour of the principles of generalism but puts down a challenge to practitioners and to the health system to put the principles into practice more effectively. We encourage you to join the debate.

Martin is Clinical Director and Director of Research and Development at the Health Foundation.