GPs work in complex clinical environments. Patients have repeated, direct access to their general practice and rate our services highly. GPs provide frontline, un-triaged, patient- focused clinical services, in which they successfully diagnose, triage, manage and optimise patients’ health. There is no other profession in which such a variety of illness and social conditions can be seen, e.g.: “my baby seems unwell and has an occasional cough”; “my wife doesn’t speak good English but has backache and her urine is sore”; “I can’t sleep at night with the pain, despite co-codamol”; “I’ve lost weight and don’t know why”; “my bowels are a bit strange”; “I have this rash on and off”; “I think I have a vaginal infection”; “I have come over the blood test, because you increased my ramipril”; “my vision went last week”; “my son has started wetting the bed”; “I feel dizzy and anxious”, “I have come with three things”.
Amid these presentations people may have multiple other problems, e.g. past cancer, carer roles, child protection plans, drug or alcohol addictions, dementia, grief, diabetes, obesity or multiple medications with potential for interactions. The modern consultation therefore is complex. Workload increases each decade, with intense pressures and unreasonably short consultation times for patients, it is little surprise that general practice is in crisis.
There are a number of other ways for patients to access medical care, e.g. NHS111, phone apps, online advice sites or forums, out of hours GP services and A&E departments, and all of these may feed in to subsequent GP appointments. If contacting the general practice directly, this might be by telephone consultation, face to face, visit request, email.
The widespread introduction of telephone consultations was not accompanied by time increases for GPs. In addition, as computerisation in the 1990s allowed employers and authorities more information on our activity, they exerted greater demand and control on GPs without looking at people, system and process capacity.
Despite this, GPs have expanded their consultation skills and developed them to include the laws and regulations associated with practice. Considerations of capacity, consent, safeguarding, confidentiality and other circumstances, such as end of life care, are now routine within the consultation and enhance patient care. GPs also develop question sets for special consultations, e.g. those with mental health, sexual health, end of life issues beyond usual consultation models.
Sharing information with patients in considering and agreeing best management has become a complex activity, sometimes lengthy and sometimes requiring revisiting by the patient. In this, GPs are expected to be experts in all latest guidance and provide the best evidence base to help the patient reach good decisions for their care. The multitude of guidance, updates, medication concerns, new medicines and procedures has become difficult for GPs to keep up with; there is simply not enough time within the working day. Despite this, GPs work to high professional standards, facilitate patient concerns and complaints and reflect on practice and personal improvement.
Within the consultation, GPs bring these strands together using their professional ethical training to weigh up the pros and cons of management options with the patient, providing best advice for the patient and allowing them to exert autonomy in making informed decisions.
There is no more interesting medical speciality, but it is one that requires longer consultation times and increased identity. As a profession we should be clearer in our skills, where they end, which we enjoy or value and do not want to lose. We should clearly define our teams and their roles, our outcomes and how we would like to work in order to enjoy practice over a 40-year period without wanting to jump ship, reduce hours, or feel overwhelmed by the burden of systems, learning and clinical work. Patients are highly satisfied with their general practices and value continuity. In the publicity about the crisis within the GP workforce, GPs need to be looking up from their clinics and speaking out.
Dr Jane Wilcock is a part-time GP at Silverdale Medical Practice Salford CCG, and university tutor and assessment lead University of Liverpool School of Medicine. She is the author of General Practice Today: a practical guide to modern consultations (https://www.crcpress.com/General-Practice-Today-A-Practical-Guide-to-Modern-Consultations/Wilcock/p/book/9781138035737)