21st century general practice
Things are going to get better
Maureen Baker was elected chair of council of the Royal College of General Practitioners (RCGP) in November 2013, and she is one of the most influential general practitioners in the United Kingdom. She is also the strategic safety adviser for the Health and Social Care Information Centre. Her clinical, educational, and research experience includes appointments at the National Patient Safety Agency, NHS Direct, and the University of Nottingham.
Describe your career path leading up to being chair of the RCGP
I went to medical school in Dundee and I wasn’t sure whether I wanted to be a GP or a paediatrician. While still a trainee I was appointed as a GP training course organiser, and that meant that early on in my career I was involved with the teaching establishment. I then did some educational and workforce research. I got a chance to represent my faculty on the RCGP Council; I thought that would be interesting so I volunteered. I’ve been on college council ever since, including being honorary secretary for 10 years. I did a range of activities alongside general practice, which is one of the great things about being a GP; it is so open to people developing additional interests.
I ended up in a position where I’d had enough college experience, clinical experience, quality research, educational experience, and emergency planning experience to stand for chair of council.
What are your main objectives for your term as chair?
My main objective is to increase the number of resources going into general practice. It has been substantially underfunded and has a current workforce problem.
General practice is like a dam. Downstream from the dam are things like accident and emergency, the acute sector of mental health, all sorts of things. The dam is in contact with all the pressure. In this analogy, water is coming over the top and out through leaks. The services downstream are starting to feel swamped and even saying that general practice, the wall of the dam, isn’t doing its job. The rest of the NHS depends on it to deal with the volume of patients and soak up all of the pressure. In 2008, there were 300 million GP consultations in England. By 2012 that had gone up to 340 million. Other parts of the NHS are feeling the squeeze but no other part of the system has had the fall in funding, the fall in resource that general practice has had.
Where do you see general practice in 10 years’ time?
I see general practice as the most vibrant, challenging (in a good way), and important part of medicine. For current students and foundation doctors it is the place to be. I strongly believe this because the challenge for 21st century healthcare is the effective management of multimorbidity. When the NHS was set up, and when I qualified in the 1980s, it was all orientated towards single disease conditions and it is still largely set up in that way today.
If you look at NICE [National Institute for Health and Care Excellence] guidelines, the studies on which most of those are constructed are carried out on people who have only single disease conditions. The populations we’ve got the evidence from are not the populations we are dealing with. GPs see someone who may have three or four conditions; they may have more. There may be three or four NICE guidelines that apply to that individual.
There is a real professional art in working with that individual to get the best regimen and the best outcomes for them, and there is little evidence around to support GPs, expert medical generalists, in doing that.
The prime minister’s pledge is for access to GPs 8 am to 8 pm, 7 days a week by the end of the next parliament, which is 2020. Labour are pledging 8000 more GPs, which we’re pleased about but they’ve also talked about guaranteed access within 48 hours. You have to be realistic if you want to achieve these aspirations. We have to have enough GPs, nurses, support staff, and funding and to be able to deliver that. It doesn’t necessarily mean that everyone works evenings or weekends. When GPs and practices work collaboratively across a federation, there should be enough opportunities for people to either work to 18 30 or for some people to do different hours if they want to.
What are the common misconceptions about a career in general practice?
I have heard it said that general practice is not sufficiently intellectually challenging. I’ve always found that interesting as I think it’s one of the most difficult jobs in medicine to do really well, all the time.
One of the things I’ve always liked about general practice is you never know what is coming in. You’ve always got to be thinking and be open to the fever that could be meningitis or pneumonia. Even [with] the most common things you’ve got to be alert, thinking and looking for cues. You’ve really got to be present, in the moment and engaged. I’ve always found it incredibly challenging and I think people who make assertions like that just don’t understand the role and don’t understand generalism.
There’s also this thing about GPs as business people, like that’s a bad thing. I think GPs take pride in running an effective service; we’re hugely cost efficient.
I have had the most fantastic, enjoyable career. Even when it’s really tough and really busy, it’s still a great job. There’s huge potential for research and for teaching. One thing that I think has been very important in making general practice an attractive career is the variety and the flexibility. Things are tough at the moment, undoubtedly, but I do think things are going to get better.
What’s your view on how the media portray general practice?
It has been appalling. GPs refer too much; they don’t refer enough. They prescribe too much; they don’t prescribe enough. GPs are overpaid and lazy or not hard working enough. If GPs were getting huge amounts of pay for very little work we wouldn’t have this problem of people emigrating, not wanting to be a GP, or retiring early, which is the situation we find ourselves in today. I do think we’ve got to the lowest point and I firmly believe things are going to start to get better. Across all the political parties there’s a realisation that something must be done to support and revitalise general practice.
Is three years’ post foundation training, long enough to train a GP if it takes seven years to train a consultant?
No it isn’t. We believe for modern general practice, with the complexity, the rules that we have for population health, commissioning, running services, leadership, we need a more substantial basis of training. We’ve been arguing for four years as a basic to get to qualification as a GP.
Any service provider can now tender for NHS services. How do you see this affecting the NHS in the longer term?
I think it’s a challenge to the ethos of the NHS. We’ve always been not for profit, free at the point of care, and paid for by the taxpayer. It’s difficult to see how patients can get as good a service when someone’s taking a profit out of the resources that are going into that. I also think that competition, certainly in the NHS, hasn’t resulted in better services for patients. I don’t think it’s been a helpful development for the NHS, and we should probably major more on collaboration and cooperation rather than on competition.
What support do you think GPs require from government?
We need the understanding that this is an absolutely vital component of the NHS that has to be appropriately funded. I hate when people talk about “out of hospital care.” Hospitals are important but such a tiny part of anyone’s experience of health. The focus on hospitals has meant that funding for general practice has been stripped to the bone, with adverse impacts on patients and services. Patients finding that they can’t get an appointment for two to three weeks worries us hugely. We feel there could be major patient safety implications in this. And the reason we’ve got to this is, frankly, lack of investment, failure to invest in general practice, and now we have a big mismatch between supply and demand.
LIFE, p 10
1University of Manchester
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.
Cite this as: Student BMJ 2015;23:h318