Role of doctors 'must change' to meet people's needs - inquiry

More of the most talented doctors must be encouraged to make careers as generalists rather than specialists to meet people’s changing health needs, an independent commission of inquiry has concluded.

The growing numbers of people living with multiple long-term health conditions need a different balance of generalism and specialism in the medical profession, both in primary and community health care and in hospitals, so that a full spectrum of care is offered consistently.

The commission, chaired by doctor and crossbench peer Ilora Finlay, is calling for new models of health care for people living at home who may from time to time, or at the end of life, need more intensive support than existing systems can offer. Special arrangements should also be made to guarantee that care homes have dedicated GP services. 

Stressing the vital importance of continuity of health care, the commission is urging those responsible for planning services to ensure that people can access care and support when they need it, 24 hours a day seven days a week.

Baroness Finlay, Commission chair, said, ‘General practice can take pride in much of the care delivered overall – but not all.  Patients are the ‘raison d’être’ of healthcare services; they need high standard whole-person care round the clock.  The first point of contact for a sick child should be a GP with appropriate training, but only about half of GPs have paediatric training.  And those in nursing homes deserve expert medical care that takes account of their vulnerabilities and complex needs.’

Baroness Finlay added, ‘A generalist approach is widely applicable across health care; from general practice through to the highly specialised services.  If generalism and general practice did not exist, we would be recommending it should be invented in the UK today.’

Commissioner Professor David Haslam said, ‘After a lifetime working as a generalist, it has been fascinating and incredibly worthwhile to go back to first principles. If you were starting to design healthcare from scratch in 2011, would generalists get a look in? The answer was resoundingly clear – there’s much more to generalism than knowing a bit about a lot. It is the essential centrepiece of a modern high quality patient-centred service, and has real potential to offer even more.’

Commissioner Clare Taylor said, ‘This report highlights the essential role that generalism plays in providing high quality, sustainable health care now and for the future.  The role of the generalist is as vital as the specialist.  When people ask me as a young GP ‘Are you a specialist or just a GP’, I am proud to say ‘Yes, I am a generalist’.

The commission was established by the Royal College of General Practitioners and the Health Foundation, to investigate and define the role and value of medical generalism in modern health care and to make recommendations about its future.

The commission’s report, Guiding Patients through Complexity: Modern Medical Generalism, comes at a time when meeting the health needs of older people, most of whom are living with at least one long-term condition, is emerging as the main challenge facing the NHS.  The report is just as relevant to hospital practice because older people recover best when specialist medical or surgical care is provided in partnership with age-friendly generalist skills.

Other recommendations include:

• Affirmation that the patient’s first presentation of illness and discussion of any treatment plan is the clear responsibility of a generalist health care professional, often but not always a doctor.
• Greater use by generalists, especially GPs, of technology to improve communication with patients and other health professionals.
• Improved training of doctors in generalist skills, including extension of GP specialist training from three years to five.

The report will be used by the RCGP as the basis of a major consultation amongst GPs and other healthcare professionals, including regional ‘listening events’. The college will consequently issue its own report next year in response to that of the commission.

Dr Clare Gerada, RCGP chair, said, ‘The Commission on Generalism is one of the most important pieces of work that the college has ever been involved in. This independent report raises questions about the concept of generalism and the role of the GP in today’s health service, as well as making some important recommendations for developing, strengthening and promoting medical generalism to deliver effective patient care in the NHS of the future.’

Professor Martin Marshall, director of clinical quality at the Health Foundation, said, ‘We are pleased to have initiated this important enquiry and thank the Commission for its excellent report.  Understanding and developing the role of the generalist alongside specialists is important for the quality of patient care, particularly ensuring the health service provides patient centred care and supports people with co-morbidities well.  We need to take up the challenge of educating the next generation of health professionals in a different way in order to realise the benefits of generalists in health care.’

Members of the Commission:

Ilora Finlay of Llandaff, Crossbench Peer, House of Lords, Professor of Palliative Medicine, Cardiff University (chair)

Susan Shepherd (secretary)

Harry Cayton, Chief Executive, Council for Healthcare Regulatory Excellence

Anna Dixon, Director of Policy, The King’s Fund

George Freeman, Professor of general practice (emeritus), Imperial College London

David Haslam, President, British Medical Association: Past president and chairman of Council, Royal College of General Practitioners: National Clinical Adviser, Care Quality Commission

Sheila Hollins of Wimbledon and Grenoside, Crossbench Peer, House of Lords, Professor of Psychiatry of Disability, St George’s University of London

Finbarr Martin, Geriatrician and Professor of Medical Gerontology, Guys and St Thomas' NHS Foundation Trust: President, British Geriatrics Society

Clare Taylor, Academic General Practitioner; First5 clinical lead, Royal College of General Practitioners