A GP has many roles, but mostly it is to act as the main point of contact for general healthcare. They treat all common medical conditions and refer patients to hospitals and other medical services for urgent and specialist treatment. In recent years, demand for their services has increased. This article highlights the most common problems seen in primary care.
GPs probably see one of the widest range of conditions of any specialty and this articles reviews some common problems and issues presenting in primary care. A recurring theme is the increasing complexity and multimorbidity we now see in modern primary care. Over the years funding has become tighter and time has become more pressurised, especially within the realms of the standard 10-minute consultation. But, over the years there has been an expansion of nurse specialists coupled with an increased input from practice nursing staff. Even so, the clinical burden (as well as the administrative burden) faced by primary care is large. GPs also have a significant role in co-coordinating care with a large number of health and social care services that are available. This is my personal top ten and they are in no particular order or preference.
I recall a time in the past when it was not unusual to refer most newly diagnosed type 2 diabetics to a consultant-led diabetic clinic. Now unless there is a specific circumstance, the diagnosis and management of the vast majority of type 2 diabetes is mainly organised from within primary care. Some of the causes of the incessant rise in the incidence of type 2 diabetes over the years are in part due to the rising levels of obesity. The Diabetes UK website1 has some impressive facts and figures about this condition. The burden of diabetes causes significant health problems and not surprisingly constitutes a significant workload within primary care. It is a chronic condition where patient education as well as pharmacological interventions and monitoring are key interventions and this is ideally suited for the primary care environment. GPs and their staff also have important roles in the management of type 1 diabetes.
Despite the vigorous attempts to reduce the impact of smoking, COPD still constitutes a significant workload for primary care. It is not only managing exacerbations, but it is the chronic disease management process that makes this condition important to primary care staff. Over the years, the use of spirometry has become increasingly prominent in primary care. As a result, staff must have the skill set not only to perform spirometry but to correctly interpret it. It is also good to see that there are specialist nurses available to add additional resources to outpatient management. Alongside COPD, asthma is also an important topic and sometimes specialist care is needed for diagnostic assistance as well as helping to managing patients with specific problems. Just like diabetes, chronic disease management is an important feature of primary care activity for both COPD and asthma.
Dermatology consultations are common in primary care and the statistics are impressive. It is thought that every year, nearly a quarter of the country attend their GP about a skin complaint.2 That equates to a heavy workload and according to the same source, just over half of the population is affected by skin disease, again every year. Referrals to secondary care are often dominated by the need to exclude skin cancer. Education both for undergraduates, GP registrars and established GPs is very important and some would argue there is a need for ongoing and significant dermatology education and support for primary care.
Again, this is another common issue that regularly appears in a GP’s surgery. It is thought that in England on an annual basis, one in six GP consultations cover an arthritic or a musculoskeletal issue.3 The scale of this can often hide the complexity of managing these conditions. GPs have to liaise with a number of healthcare professionals such as physiotherapists, orthopaedic surgeons and rheumatologists as well as nurse specialists, to name a few. In addition, rheumatology has evolved into a specialty that has introduced a number of sophisticated drugs that requires regular monitoring. GPs often have to prescribe these drugs and have to organise the monitoring of these agents and sometimes this can be a significant logistical operation. New drugs and new techniques are evolving all the time.
This is very much the bread and butter of general practice and it is unusual for this condition to be managed outside primary care on a continuing basis unless something unusual is going on. It could be a hypertension that could be difficult to control and there could be a secondary cause of the hypertension. Management has been made easier by web-based access to national guidance or easily accessible and trusted knowledge resources such as https://cks.nice.org.uk/hypertension-not-diabetic Primary care is ideally suited for the long-term management of this condition and associated medication reviews.
Cardiac problems again constitute a significant part of everyday primary care. Sometimes GPs have to deal with the diagnosis of coronary artery disease, which can present acutely or more insidiously. Establishing or even suspecting the diagnosis of angina in primary care is not always easy, especially in the context of seeing numerous other non-specific symptoms and presentations. Angina which is not typical is not always easy to diagnose on first presentation. Just as important is to manage the people with long-term cardiac problems who require regular surveillance and medication reviews. This is where electronic records excel at helping guide the clinician to see who needs a review.
Occasionally, GPs have to manage with the acute presentation of acute stroke or a transient ischaemic attack (TIA) and arrange appropriate acute care. But, a much more common scenario is managing the community based aspects of the long-term impact of stroke. This will include making sure the patient is taking the correct medication with the most appropriate monitoring and helping to co-ordinate the various other services that may be involved. Assessing and signposting services for carers, if appropriate, are also important and this really applies to most chronic conditions.
Primary care plays an important role in the management of chronic illness both in terms of diagnosis and management of a large number of problems. But, primary care also has a large role in dealing with acute illness. The breadth and number of clinical situations is huge and although a significant majority of presentations are benign and self limiting, a small number of presentations could be serious or even life threatening. It is not always easy to pick out these people who may have acute and serious illness, especially in early and non-specific presentations. Yet failure to detect this important minority could have devastating consequences for both the patient and the health care professional. In addition, acute illness presentation constitutes a significant workload for primary care, especially when there is a demand by patients to be seen quickly.
GPs have a substantial input throughout the whole cancer pathway. They are often in the frontline in diagnosing cancer, often assisted by the two-week cancer pathways.4 Some symptoms and signs are clearly red flags and need urgent referral. But, sometimes it is not always easy to pick out the early presentations of a malignancy with non-specific early symptoms and signs. So GPs always need to be on alert to detect early and serious disease. Once cancer is diagnosed, GPs often have to provide long-term emotional and clinical support during the management and treatment process. Sadly, some people will also need terminal care and if they are to receive it at home, GPs will also be significantly involved.
GPs do a lot of prescribing; not only is this initiated by themselves, but often on behalf of third parties such as secondary care. Watching for drug interactions, managing large numbers of repeat prescriptions and trying to rationalise the long lists of medications that some patients are taking, are just some of the prescribing tasks that GPs manage on a daily basis. In addition, prescribing and therapeutics is a fast moving discipline with new products and new indications appearing all the time. Thankfully, with the aid of computerised prescribing as part of GPs electronic clinical records system, not only are printed prescriptions legible but prescribing in general, is easier to manage.
This article is only a snapshot of what GPs do on a daily basis and from a clinical perspective shows some of the work that GPs perform day in and day out. In a way, it shows how varied a GP workload can be, but it equally highlights how much knowledge and skills, a GP must possess in order to provide a high quality service. In addition, it is imperative that GPs keep up-to-date in a large number of disciplines and clinical areas. The administrative burden of running a practice can also be significant and perhaps this combination and intensity of workload is a contributory factor to some of the GP recruitment and retention problems seen in some areas of the country. GPs are under pressure just like the rest of the NHS, but hopefully primary care can continue to provide a high quality service to their patients.
Dr Harry Brown
GM Clinical Editor and GP, Leeds