#GPFUQ 71 Are you a broad or a narrow generalist?
Narrowists do very little and must refer everything for someone else to do later.
Broadists try to do everything needed now themselves.
A generation ago – a GP was an unrestricted broad generalist and could
do most things. Skills were learnt on the ‘see one, do one, teach one, then
delegate one’ model. Over the course of a 30 year career there is a shift in
the skills that a GP wants and need to provide in normal working practice. At
the beginning of a career a doctor may be eager to learn to do a procedure, at
the end of a career the same doctor may have delegated the procedure to another
member of the team. At times a GP might still need to be able to ‘do one’. In
the same practices different GPs would be at different stages of the ‘see one,
do one, teach one, and delegate’ model’.
Some GPs would always be narrowists and opt out of doing things. What a
doctor can do and or is prepared to do depends on the doctor him/herself (e.g.
knowledge, skills and attitudes), the patients characteristics (e.g. urgency of
condition, expectations, personality), the practice culture (e.g. whether its
more self serving or customer serving) its resources (e.g. the support
available in the practice), the bureaucracy set by local and national NHS (e.g.
the remuneration processes at work, statutory obligations), the current fashion
or evidence for care, any formal accreditation of competencies, the prevailing
culture for risk management, and the particular circumstances specific to a
given day (e.g. what else is happening that day). The sum of all the current
influences seems to creating more narrowist GPs. Everything must be referred to someone else for action. How can this trend that may
create GPs who can’t do much for their patients be reversed?
Good patient experience
comes if the GP has and uses a breadth and depth of knowledge and skills and
there is good communication with, dignity and respect for, and involvement in
decisions with the patient. Each GP has to stop and think about what is shaping
his/her performance and be able to defend his/her actions as ‘the best option
available for the patient at that particular time’. Each GP should do whatever needs to be done him/herself now and challenge
any blocks to being a broad generalist .
#GPFUQ 72 Should GPs provide
only basic or extra services?
If GPs don’t do the work – will GPs become deskilled? There are contrasting views about what GPs should be able and prepared to do. The basic skill set for some GPs is considered extended roles by other GPs. Many patients, and practices want GPs who provide more than the basic care, and many GPs want to develop or maintain special expertise. Most money is spent on secondary care, and a higher percentage of the little spent on primary is still not much, so it makes sense to invest more in primary care especially if it can reduce the costs of secondary care. However opinions seem divided about whether GPs should routinely provide extended services. Some GP want to stop trying to provide services such as pre op and post op care, counselling patients, advising re smoking, and other lifestyle advice - diet, exercise, cholesterol etc, dealing with stress and mild depression, and any secondary care work delegated to GPs. Other GPs want to take on more services such as more active involvement in antenatal and maternity care, identify and proactively contact their patients with Learning Disabilities, adolescent medicine, ultrasound scans, palliative care, more minor surgery, extended consultations in mental health, Mirena insertions, male screening, open healthy cafes, hosting weight loss boot camps.
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Suggestions for action
- Each year
identify what services are needed locally, which are the priority for that
year, and collaborate with others to provide these services
- Each year
identify what skills each GPs or staff member wants to develop or continue
for their own professional development and satisfaction and try to provide
a development plan and opportunity
- Make a
business case for any GP specialist services and seek appropriate funding
- Delegate as
much as possible by acting as a communication "hub" to provide services e.g. make community matrons be utilised as much as possible
- Sort patients
together to provide a scheduled group based solution eg group diabetes
education session, group stop smoking sessions
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