Commission on Generalism Consultation

COMMENTS ON ROYAL COLLEGE OF GENERAL PRACTITIONERS
COMMISSION ON GENERALISM CONSULTATION

The Royal College of Physicians of Edinburgh (the College) is pleased to respond to the Royal College of General Practitioners on its Commission on Generalism consultation.

The College recognises the importance of generalist practice in secondary care as patient demand and technological advances drive ever increasing specialisms.  Medical generalism will remain a vital part of secondary care, both for those presenting with multiple problems and those presenting as emergencies that require urgent intervention beyond the capacity or resources of primary care.  This is particularly pertinent in remote and rural parts of Scotland.

The College has the following answers and comments on specific consultation questions:  

In the College’s understanding, the term medical generalism usually refers to a holistic approach to the assessment and treatment of patients who may have a wide range of symptoms.

The core values of medical generalism embrace a holistic approach, which is multidisciplinary and involves whole-system integrated care.

In addition, the following values are important to the understanding of medical generalism:

The values described in the previous questions are frequently shown in general practice, and also in specialties such as geriatrics and in much of paediatrics.  They are also of particular relevance in the treatment of people with chronic conditions and in palliative care. 

There may be challenges to implementing these values because of limitations of availability and work patterns etc.

All subspecialties need good core generic medical practice: looking at the whole person, respecting patients, communicating well and understanding relevant evidence, but as frontiers of medicine expand, there is a need to strive to achieve the correct balance between generic good practice and specialist expertise, and to recognise the limitations of both.

A major issue for medical generalism in the twenty-first century is to make it clear that developing and maintaining general skills is as challenging as specialist expertise in a more focused area, and requires at least equivalent levels of training.  

Risks associated with medical generalism can be mitigated by ensuring that generalists work in teams (actual or virtual) both to reduce professional isolation and to allow some specialisation among team members; and by facilitating speedy access to specialist advice when needed. 

It is important that referral pathways must be flexible enough to fit patients who may not fit into any neat box, and the role of a GP in directing patient referral appropriately is crucial.

Medical generalists, and indeed perhaps general physicians and surgeons more than others, are sometimes labelled as being 'jack of all trades but master of none'.  However, particularly in remote and rural areas, this general expertise offers local and emergency access to essential services.  A typical example of this is given from a Fellow of the College who practices as a General Physician in a rural general hospital, and states that he has a very wide remit within hospital general medicine which can include psychiatry, paediatrics and community care.

The essential competence of the generalist in all areas is knowledge of one’s own level of competence and when to seek help, and from whom, in any given situation.  In this context, the development of managed clinical networks, and links with specialist colleagues in central hospitals, is vital.

The Commission could help to define the limits in contemporary healthcare of what is safe and clinically effective generalist practice.

Threats and challenges to medical generalism include:

The College recognises the importance of generalist practice in secondary care as patient demand and technological advances drive ever increasing specialisms.  Medical generalism will remain a vital part of secondary care, both for those presenting with multiple problems and those presenting as emergencies that require urgent intervention beyond the capacity or resources of primary care.

It is vital not to downplay the importance of specialist expertise but also to endorse the benefits - for patients and for the NHS - of generalist expertise.  Professionally, this is already happening as general practice becomes a more popular career choice for medical graduates, but more could be done in medical education to emphasise the importance of holistic medicine.

As far as patient expectations are concerned, the merits of the generalist contribution - in terms for example of early diagnosis, caring for and treating the whole person and coordinating care within the NHS and with other agencies - need to be publicised, something to which the Commission could make a very valuable contribution.

At present incentives and rewards eg discretionary points have tended to follow those who become very specialised and who may opt out of generalist care.

It is important to encourage and reward colleagues who assist in the management of complex and challenging cases.  However, there is also a need to support and incentivise excellent generalist activity.  A solution may be for all specialists to be expected to participate in some generalist activities in the formative years of their career.

Trainees should be exposed to the general medical challenges of colleagues in district and rural general hospitals, and general care (especially of emergencies) must be part of all training. Greater awareness might encourage cross fertilisation between general practice and hospital specialties.

Due to focus on very particular specialisms, there is actually an increasing role for the generalist who can translate all the specialist help into practical, realistic and effective therapy and care and have an overview of the impact and interplay of multiple illnesses, and the influences and limitations of the real world in which the patient lives. 

There is a need for practical debate and collaboration, where specialism and generalism are seen as two ends of a continuum of care, and for each facet of a patient’s problem there will be an appropriate balance between these in order ultimately to provide the optimum quality of care.

1. What do you understand by the term medical generalism? Where you can, please give examples of where you see it:
   1. In general practice
   2. In other settings
   1. Within general practice, it is seen in those colleagues who will manage the overwhelming majority of patients without need for secondary referral but who will refer to specialist services selectively and appropriately, often after initial investigation.
   2. In secondary care, paediatricians and geriatricians are often the most likely to take a generalist approach within some constraints of age, whereas emergency physicians and acute physicians must take a generalist approach albeit over a short period of time.
2. What are the core values of medical generalism?
   • Providing a consistent approach to the delivery of care on an ongoing basis;   
   • Ensuring good communication and smooth transfers of care;
   • Timely escalation prioritised on the basis of clinical need; 
   • Care closest to home as is realistic and feasible;  and
   • Taking a considered approach to risk.
3. How do the values you describe fit with what you recognise as generalism in practice (as you outlined in your response to question one)?
    
4. Where do the boundaries of medical generalism lie?  What are the challenges at the interface of medical generalism with other areas of practice?
5. Are there elements considered to be part of medical generalism that ought to be modified or abandoned? Does medical generalism need to adapt, and if so, how?
6. What threats and challenges do you think medical generalism faces today?  What threats and challenges do you foresee in the next 10 to 15 years?
    
   • An ageing population;
   • Pressure on limited financial resources;
   • A societal review of real risk;
   • A more demanding public not necessarily focused on medical need; and
   • Prematurely early specialisation and divergence of CPD and professional experience, leading to a loss of confidence in managing general problems amongst those with narrower fields of interest.
7. What can be done to strengthen medical generalism – particularly those aspects that you care about? How would you propose to go about doing this?
8. What recommendations would you make about the future development of medical generalism; are there particular aspects of this that relate solely to general practice?
   • Generalism has been one of key strengths of UK Medicine over the last sixty to seventy years.  The concept requires revision, refocus and reprioritisation to reflect the demands of scientific and technological advances and greater patient focus.
   • The balance between generalist and specialist care must be redressed to benefit overall patient care, ensuring NHS resources allow generalist practice to flourish in the community taking care not to erode the provision of specialist care for patients requiring it.
   • It is important to raise the profile of generalist work both in primary and secondary care.