General practice

General practice is the name given in the United Kingdom to the service provided by General practitioners. In other countries similar services may be described as family medicine or primary care. The term Primary Care in the UK may also include services provided by community pharmacy, optometrist, dental surgery and community hearing care providers. The balance of care between primary care and secondary care - which usually refers to hospital based services - varies from place to place, and with time. In many countries there are initiatives to move services out of hospitals into the community, in the expectation that this will save money and be more convenient.

India

A group of 15 doctors based in Birmingham have set up a social enterprise company - Pathfinder Healthcare - which plans to build eight primary health centres in India on the British model of general practice. According to Dr Niti Pall, primary health care is very poorly developed in India. These centres will be run commercially. Patients will be charged 200 to 300 Rupees for an initial consultation, and prescribed only generic drugs, dispensed from attached pharmacies.^[1]

Ireland

In Ireland there about about 2,500 General Practitioners working in group practices, primary care centres, single practices and health centres.^[2]

United Kingdom

The pattern of services in the UK was largely established by the National Insurance Act 1911 which established the list system which came from the friendly societies across the country. Every patient was entitled to be on the list, or panel of a general practitioner. In 1911 that only applied to those who paid National insurance contributions. In 1938 43% of the adult population was covered by a panel doctor.^[3] When the National Health Service was established in 1948 this extended to the whole population. The practice would be responsible for the patient record which was kept in a "Lloyd George envelope"^[4] and would be transferred if necessary to another practice if the patient changed practice. In the UK, unlike many other countries, patients do not normally have direct access to hospital consultants and the GP controls access to secondary care.^[5] Practices were generally small, often single handed, operating from the doctor's home and often with the doctor's wife acting as a receptionist.^[6]

Lloyd George envelopes at Whalsay Health Centre 2012

In 1953, general practitioners were estimated to be making between 12 and 30 home visits each day and seeing between 15 and 50 patients in their surgeries.^[7]

Services are provided under the General Medical Services Contract, which is regularly revised.

England

The GP Forward View, published by NHS England in 2016 promised £2.4 billion (14%) real-terms increase in the budget for general practice. Jeremy Hunt pledged to increase the number of doctors working in general practice by 5,000. There are 3,250 trainee places available in 2017. The GP Career Plus scheme is intended to retain GPs aged over 55 in the profession by providing flexible roles such as providing cover, carrying out specific work such as managing long-term conditions, or doing home visits.^[8] In July Simon Stevens announced a programme designed to recruit around 2,000 GPs from the EU and possibly New Zealand and Australia.^[9]

GPs are increasingly employing pharmacists to manage the increasingly complex medication regimes of an aging population. In 2017 more than 1,061 practices were employing pharmacists, following the rollout of NHS England’s Clinical Pharmacists in General Practice programme.^[10]

Four NHS trusts: Northumbria Healthcare NHS Foundation Trust; Yeovil District Hospital NHS Foundation Trust; Royal Wolverhampton NHS Trust; and Southern Health NHS Foundation Trust have taken over multiple GP practices in the interests of integration.^[11]

Number and size of practices

599 GP practices closed between 2010–11 and 2014–15, while 91 opened and average practice list size increased from 6,610 to 7,171.^[12] In 2016 there were 7,613 practices in England, 958 in Scotland, 454 in Wales and 349 in Northern Ireland.^[13] There were 7435 practices in England and the average practice list size in June 2017 was 7,860. There were 1.35 million patients over 85.^[14] There has been a great deal of consolidation into larger practices, especially in England. Lakeside Healthcare was the largest practice in England in 2014, with 62 partners and more than 100,000 patients. Maintaining general practices in isolated communities has become very challenging, and calls on very different skills and behaviour from that required in large practices where there is increasing specialisation.^[15]

GP Federations have become popular among English General practitioners. ^[16]

Consultations

According to the Local Government Association 57 million GP consultations in England in 2015 were for minor conditions and illnesses, 5.2 million of them for blocked noses.^[17] According to the King's Fund between 2014 and 2017 the umber of telephone and face-to-face contacts between patients and GPs rose by 7.5% although GP numbers have stagnated.^[18]

The proportion of patients in England waiting longer than seven days to see a GP has risen from 12.8% in 2012 to 20% in 2017.^[19]

A private GP service was established at Poole Road Medical Centre in Bournemouth in 2017 where patients can pay to skip waiting lists to see a doctor.^[20]

Northern Ireland

There have been particularly acute problems in general practice in Northern Ireland as it has proved very difficult to recruit doctors in rural practices.^[21] The British Medical Association collected undated resignation letters in 2017 from GPs who threatened to leave the NHS and charge consultation fees. They demanded increased funding, more recruitment and improved computer systems.^[22]

References

Further reading

• William G. Rothstein (1987). American Medical Schools and the Practice of Medicine: A History. Oxford University Press. ISBN 978-0-19-536471-2.