General practice

General practice is personal, family, and community-orientated comprehensive primary care that includes diagnosis, continues over time and is anticipatory as well as responsive.^[1]

Definitions

A general practitioner (GP) is a doctor who is a consultant in the discipline of general practice. GPs have distinct expertise and experience in providing whole person medical care whilst managing the complexity, uncertainty and risk associated with the continuous care they provide. GPs work at the heart of their communities, striving to provide comprehensive and equitable care for everyone, taking into account their health care needs, stage of life and background. GPs work in, connect with and lead multidisciplinary teams that care for people and their families, respecting the context in which they live, aiming to ensure all of their physical health and mental health needs are met.^[2]

General practice is an academic and scientific discipline with its own educational content, research, evidence base and clinical activity. Characteristics that define the discipline of general practice are:^[1][3]

• person centredness
• continuity of care
• comprehensiveness
• whole person care
• diagnostic and therapeutic skill
• coordination and clinical teamwork
• continuous quality improvement
• professional, clinical and ethical standards
• leadership, advocacy and equity
• continuing evolution of the speciality.

The general practice model is used in countries such as the United Kingdom, Australia, New Zealand, the Netherlands, India and South Africa. In some countries, such as the United States, similar services may be described as family medicine or primary care. The term primary care may include services provided by GPs, community nursing, allied health, pharmacy, optometrist, dentistry, 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. In many countries there are initiatives to move services out of hospitals into the community, in the expectation that this will be cost-effective and be more convenient.

Ireland

In Ireland there are about 2,500 General Practitioners working in group practices, primary care centres, single practices and health centres.^[4]

Australia

General Practice services in Australia are funded under the Medicare Benefits Scheme (MBS) which is a public health insurance scheme. Australians need a referral from the GP to be able to access specialist care. Most general practitioners work in a general practitioner practice, supported by practice nurses and administrative staff. Often other health professionals such as allied health practitioners and pharmacists are part of general practice teams to provide an integrated multidisciplinary healthcare team to deliver primary care.^[5]

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.^[6] When the National Health Service was established in 1948 this extended to the whole population. The practice would be responsible for the patient record 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.^[7]

Most services are provided under the General Medical Services Contract, which is regularly revised.^[8] GPs could always see patients privately - for payment - but until recently that was rare. They have to be registered as independent consulting doctors. In the 2020s the number doing so increased considerably. Most also work for the NHS, but they report that private work is less stressful.^[9]

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.^[10] In 2019 according to NHS England, almost 90% of salaried GPs were working part-time.^[11]

Under the pressure of the Coronavirus epidemic in 2020 general practice shifted very quickly to remote working, something which had been progressing very slowly up to that point. In the Hurley Group Clare Gerada reported that "99% of all our work is now online" using a digital triage system linked to the patient's electronic patient record which processes up to 3000 consultations per hour. Video calling is used to "see" patients if that is needed.^[12]

Overloading of GP services led to effective healthcare rationing through what was known as the "8am scramble", causing patient dissatisfaction.^[13]

More than 80% of GPs feared patients may be at risk from bad decisions because GPs are overworked and understaffed in March 2022.^[14] In September 2022 1.45 million patients waited at least 28 days before seeing a GP. In November 2022 GPs told The Observer most days they breach the British Medical Association (BMA) guideline of "not more than 25 contacts per day" to provide safe care. In March 2021 Pulse did a survey which revealed GPs were dealing with 37 patients per day on average.^[15]

Premises

This section needs to be updated. Please help update this article to reflect recent events or newly available information. (July 2023)

Practices were generally small, often single handed, operating from the doctor's home and often with the doctor's wife acting as a receptionist.^[16] When the NHS was established in 1948 there were plans for the building of health centres, but few were built. The British Medical Association in 2019 conducted a survey for GP premises. About half of the 1,011 respondents thought their surgeries were not suitable for present needs, and 78% said they would not be able to handle expected future demands.^[17]

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.^[18] In 2016 there were 7,613 practices in England, 958 in Scotland, 454 in Wales and 349 in Northern Ireland.^[19] 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.^[20] 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.^[21] By 1 October 2018, 47 GP practices in England had a list size of 30,000 or more and the average list size had reached 8,420.^[22] In 2019 the average number of registered patients per GP in England has risen since 2018 by 56 to 2,087.^[23]

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.