Crammer's Corner
GP Specialty Registrar, RCGP National GP Trainee Representative and Deputy Chair of the AiT Committee
GP at The Fern Hill Practice, Faringdon, and RCGP Curriculum Development Fellow
E-mail: clarejtaylor{at}doctors.org.uk
E-mail: ben.riley{at}nhs.net
As the training year draws to an end for many GP Specialty Registrars, this issue of Crammer's Corner looks beyond the nMRCGP assessments and gives a GP Specialty Registrar's summary of the current changes affecting doctors entering the wider world of general practice.
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General practice beyond nMRCGP |
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 TOP General practice beyond nMRCGP The Darzi review and...The Federated ModelPrivatizationThe current situationWe are the futureReferences |
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General practitioners (GPs) in training can sometimes be accused of focusing too much on exams while working towards their ultimate goal of achieving a Certificate of Completion of Training (CCT) for general practice; completing Workplace-based Assessment, keeping the ePortfolio up to date and preparing for the Applied Knowledge Test and Clinical Skills Assessment take up a great deal of time and energy.
It may be to the detriment of a future GP, however, if he or she fails to engage with the challenges and potential threats currently facing general practice or does not appreciate the impact these changes will have on his or her career post-CCT.
The core curriculum statement, Being a General Practitioner, not only describes the competencies required to provide comprehensive, holistic and patient-centred care to the patients seen every day in the practice but also encompasses a wider understanding of what it is to be a GP in the 21st century (see Fig. 1).
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The Darzi review and polyclinics |
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TOPGeneral practice beyond nMRCGPThe Darzi review and...The Federated ModelPrivatizationThe current situationWe are the futureReferences |
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In summer 2007, Lord Darzi was asked by Alan Johnson, Secretary of State for Health, to lead the NHS Next Stage Review for the Department of Health with the aim of ‘setting out a new vision for a 21st Century NHS’. Lord Darzi is an NHS Consultant Surgeon based in London who specializes in minimal access surgery. His consultation, Our NHS, Our Future, which completed earlier this year, was intended to gather information from patients, staff and the public to inform recommendations for change and improvement in the NHS over the next decade.
During the review, Lord Darzi was famously associated with the term ‘Polyclinic’, which conjures up images of huge buildings staffed by anonymous health care workers miles away from patients’ homes. The image on the cover of a recent edition of the British Medical Journal, depicting a large, complex, unwelcoming building, may aptly illustrate what some fear a polyclinic might look like.
Polyclinics, as large community-based facilities housing GPs, other health care professionals and diagnostic services, have been suggested as a potential model for providing better health care to under-doctored, poorly resourced areas. In his consultation document, Healthcare for London: A Framework for Action, which specifically looked at health service provision in the capital and was published in July 2007, Lord Darzi referred to polyclinics as a means of improving access to a wide variety of services not currently offered by GP surgeries while being less medicalized than hospitals.
Polyclinics have been criticized for a ‘one size fits all’ approach to health care and some fear the essence of general practice may be lost in these large centres. The term ‘Martini health care’—anytime, anywhere, any doctor—has been used to describe the effect of introducing polyclinics more widely. The ideal of a GP providing lifelong continuity of care to patients and their families would be lost. As a consequence of these criticisms, the term polyclinic has fallen out of favour but some fear it may just be rebranded rather than gone for good.
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The Federated Model |
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TOPGeneral practice beyond nMRCGPThe Darzi review and...The Federated ModelPrivatizationThe current situationWe are the futureReferences |
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The Royal College of General Practitioners (RCGPs) have set out a vision of what the future of general practice should look like, in a landmark ‘Roadmap’ document that was unveiled in September 2007. The document, endorsed by many stakeholders including the British Medical Association (BMA), outlines a new ‘Federated Model’ of health and social care with multiple existing practices working together. The Federated Model involves surgeries sharing expertise and having access to diagnostic tests and other support services, like mental health teams, which would allow GPs to deal with most health issues out in the community, leaving hospitals free to deliver true acute care and major surgical services. This model puts the generalist at the heart of patient care and allows the values already embedded in general practice to be maintained.
The extensive GP curriculum is designed to adequately train us for this role. In his report, Aspiring to Excellence, which followed the independent enquiry into Modernizing Medical Careers, Sir John Tooke recommended that training in general practice should be extended to 5 years, a sure reflection of general practice finally being acknowledged as a full ‘speciality’ in its own right. With the most comprehensive training curriculum of all the clinical specialities, GPs will be well equipped to deliver complex care from childhood to end of life close to patients’ homes, including chronic disease management and promoting health in the community (see Fig. 2).
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Privatization |
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TOPGeneral practice beyond nMRCGPThe Darzi review and...The Federated ModelPrivatizationThe current situationWe are the futureReferences |
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In her book, NHS plc, Allyson Pollock discusses the increasing involvement of the private sector in providing health care to the modern NHS. She describes the systematic dismantling and privatization of large parts of the NHS, mainly in relation to secondary care. This book was written a couple of years ago but alludes to the potential threat facing general practice in the future from private providers purchasing premises, converting GPs into salaried employees and maximizing profits by referring patients to services also provided by the company. There are now private firms entering the market, building new surgeries and tendering for Alternative Personal Medical Services contracts.
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The current situation |
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TOPGeneral practice beyond nMRCGPThe Darzi review and...The Federated ModelPrivatizationThe current situationWe are the futureReferences |
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In his Our NHS, Our Future Interim Report in October 2007, Lord Darzi described a vision of a fair, personalized, effective, safe and locally accountable health care system. Furthermore, in his most recent document, NHS Next Stage Review—Leading Local Change published in May, he goes on to describe five pledges that in delivering improvement Primary Care Trusts must ensure any change is for the benefit of the patients, clinically driven and locally led with patient and public involvement with no removal of existing services until better ones are in place. None of us would disagree with such generic statements of intent but we wait to see what the final report recommends in practice.
The RCGPs held a workshop to discuss in more detail what the Federated Model should encompass and is publishing its own recommendations for the future shape of general practice (www.rcgp.org.uk).
The BMA has recently launched a Support Your Surgery campaign and will be sending out campaign packs to every GP practice in the UK to allow surgeries to inform patients of the changes happening in general practice.
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We are the future |
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TOPGeneral practice beyond nMRCGPThe Darzi review and...The Federated ModelPrivatizationThe current situationWe are the futureReferences |
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Now in its 60th year, the NHS continues to be the envy of the world, providing comprehensive, high-quality health care free at the point of delivery. GP Specialty Registrars are the future workforce of general practice and will form the cornerstone of the NHS. It is our responsibility, as GPs, to remain informed and involved in the political process. This is not just a job for the medicopoliticians but for everyone who cares about the future of the NHS and maintaining the holistic, comprehensive, person-centred approach to health care we spend so much time training to deliver. Only by understanding the impact of changes and informing patients of these and having a clear vision of what we want the NHS to look like in the future, can we ensure the principles of general practice are protected.
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References |
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TOPGeneral practice beyond nMRCGPThe Darzi review and...The Federated ModelPrivatizationThe current situationWe are the futureReferences |
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Johnson A. NHS Next Stage Review announcement. Accessed via www.publications.parliament.uk/pa/cm200607/cmhansrd/cm070704/debtext/70704-0004.htm#07070441000007 (date last accessed 25.05.08).
Pollock AM. NHS plc—The privatisation of our health care. Verso (2005).
When is a polyclinic not a polyclinic? [Cover of British Medical Journal (April 26 2008). BMJ (2008) 336.
Field S. Say no to "martini" health care. British Journal Of Hospital Medicine (2008) 69:124–5.[Web of Science]
Finch R. When is a polyclinic not a polyclinic? BMJ (2008) 336:916–8.
Darzi L. Our NHS, Our Future: NHS Next Stage Review Interim Report October 2007. Accessed via www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/dh_079077 (date last accessed 25.05.08).
Darzi L. Our NHS, Our Future: NHS Next Stage Review Leading Local Change (2008) England: Department of Health. Accessed via www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_084644 (date last accessed 25.05.08).
Darzi A. Healthcare for London: A framework for action. Accessed via www.healthcareforlondon.nhs.uk/pdf/aFrameworkForAction.pdf (date last accessed 25.05.08).
Tooke J. Aspiring to Excellence. Findings and final recommendations of the independent inquiry into modernising medical careers. (2008) Accessed via www.mmcinquiry.org.uk/Final_8_Jan_08_MMC_all.pdf (date last accessed 25.05.08).
Riley B, Haynes J, Field S. The Condensed Curriculum Guide (2007) London: RCGP.
Royal College of General Practitioners. The Future Direction of General Practice—a roadmap (2007) London: Royal College of General Practitioners. Accessed via www.rcgp.org.uk/roadmap (date last accessed 25.05.08).
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