Prof. Geoffrey Meads writes from Winchester, UK, where he is Emeritus Professor of Wellbeing Research at the University of Winchester. An organisational sociologist with extensive experience of policy and practice in primary and community care, he was previously a National Health Service regional director and health authority chief executive.
Directness is a basic requirement of relational proximity. Face-to-face encounters, open communication, transparency and shared space are prerequisites for relationships of commonality, trust and tolerance. This has long been a key message of Relationists.
In the UK directness used to be at the heart of general medical practice. Registering with a general practitioner (GP) meant a personal lifelong commitment. This was universal and comprehensive in its coverage of physical and mental health, within a pastoral context of a patient’s family and a doctor’s defined locality. As a result, British GPs have undertaken a broader social medicine approach than counterparts with more limited specialist and secondary clinical care perspectives in other countries. This scope of UK general practice brought the profession political influence. GPs have been both legitimate advocates for individuals’ welfare rights and central government agents for implementing National Health Service policies.
This approach is now at risk. Newspapers report a service ‘in crisis’: a term liberally employed in the GP Pressures Report 2023 of the Royal College of General Practitioners (RCGP). In Doomsday language this describes shortfalls in recruitment, IT and management systems, and service funding. A quarter of general practices are perceived to be close to closure. GP retention especially is a crucial issue with 19 000 doctors (over half the total workforce) ready to resign, according to the Report. Moreover this crisis occurs when demand is unprecedented: with 370 million consultations logged in 2022.
Most of these are not in person; and if they are they may not be with a GP. In my local practice I am directed to make first contact via an online format. Referral screening and triage is through a dedicated care navigator system. Its staff are available for structured telephone interviews and instructions only once multiple options – such as nurse dressing and blood tests – have been set out in a five minutes long GP recorded message.
The consequence is a loss of interpersonal directness, and a decline in both public confidence and GP morale. There is no prospect of turning back the clock. Indeed the 2023 RCGP plan Fit for the Future emphasises how improved IT connections can deal efficiently with both patients and other professionals. If directness is to underpin future UK general practice it clearly has to denote something more than just an individual relationship.
Accordingly, RCGP objectives now include a ‘new’ key role for GPs of ‘supporting community wellbeing initiatives’. Globally this represents a significant shift from primary medical to primary health care. To retain the special status and values of GPs in UK society a reframing of previously uni-professional business partnerships as community social enterprises will be required; and a fundamental reappraisal of GP’s direct relationships as a result .
Comments and discussion are welcome (see below). Please note that comments will be moderated to avoid trolling and spamming, and so will not appear immediately.
Thank you Prof Meads.
As a practising GP, I think there are 2 pressures at hand which significantly impede directness – dwindling workforce numbers (from chronic underfunding and GP-bashing) and altered patient behaviour. The two are intricately intertwined and responsible for the lack of sustainability of General Practice as it stands.
Furthermore and perhaps more pertinently, it is the ‘patient behaviour’ which has significantly changed even in the last 10 years. People take little responsibility for their own health and seek advice at the drop of a hat – often for things which will get better on their own. Gone are the days when they would seek advice from a friend or relative and heed it. We are experiencing the ‘next-day Amazon Prime generation’ to the detriment of healthcare. No longer do people wait any time at all to see if things settle on their own.
In many ways that is why the almost ubiquitous online form has emerged. It is the ONLY way to deal with the workload. GPs have to triage and select what they and others in the team see because they themselves cannot and should not see everyone who wishes to be seen (eg a patient who ran 10km, the next day, contacted us requesting an immediate appointment and scan for their aching knee!). Interestingly, often the triaging of these forms is in fact done by a GP and so a patient query is direct to GP even if it may not feel like it!
We are a city centre practice and yesterday, following the bank holiday, on top of our pre-booked appointments, we had 210 patients (nearly 2% of our list) contact us during the day requesting GP input. GPs often enjoy directness and that is one reason why people sign-up to be in primary care, to be at the coal-face, but this sheer workload and the government policy of moving funding to outsource GP work to excellent (and cheaper) colleagues such as pharmacists, physios, physicians’ assistants means that directness of access to your GP is going to be harder to achieve rather than easier, sadly.