Enhancing generalism

Purpose and context

General practitioners, as a specialty, personify the concept of generalism in medicine for many people, and there is a considerable body of evidence showing that quality of care, health outcomes and satisfaction with care are increased when there is continuity of care.

Continuity is increased when the patient has an ongoing relationship with their GP, who sees them as a whole person and not just as someone with a specific ailment. Indeed, the rapid and large-scale response from general practice to the COVID-19 pandemic was aided significantly by longstanding relationships with the patients and populations we serve.

The citizens we serve are living longer with multiple co-morbidities and often-complex social and care issues, presenting greater need for care of the whole person and not just diseases, conditions, or even single episodes. In response to this need, this reform strand was initially designed around addressing quality of care, compassion and holism.

Alongside this work sits the Health Education England Enhance programme, which seeks to enhance generalist skills across foundation and specialty training, and to deliver the General Medical Council (GMC) Generic Professional Capabilities (GPCs). The overlap of Enhance and this workstream is such that the GPST reform programme will incorporate Enhance.

The intended benefits of the Enhance programme:

a) Patients

• To improve patient experience and outcomes, through delivery of more holistic and personalised care.

b) Healthcare professionals

• To support improved stewardship and the delivery of value-based care within the NHS
• To provide access to new learning that students and trainees recognise as important and more self-determined professional development opportunities
• To provide opportunities for multi-disciplinary and multi-professional learning
• To provide access to more varied, flexible and rewarding careers
• To support implementation of a ‘shared-leadership’ approach.

c) Wider health and care system

• To support a new professional perspective where generalist and specialist skills are valued equally – improving the breadth of healthcare professionals’ impact and the culture in which they work
• Enable more flexible workforce planning
• To support delivery of integrated care through place-based, locally focused training aligned with the NHS Long Term Plan and maturing ICS agendas
• To support innovative health and care teams that are diverse, inclusive, encourage widening participation and enable new emerging roles to flourish
• To support workforce retention with improved productivity and wellbeing.

On a practical level, this will mean liaising with the national Enhance team and encouraging local GP educators to engage with the Enhance pilots locally. GP DiTs should be given opportunities to learn with those on Enhance programmes, both on shared placements and in teaching sessions. This would highlight shared learning across medical specialties and emphasise the Enhance aim to embed multiprofessional learning in teams across secondary care.

We heard...

Many people we engaged with feel the role of the GP has become less generalist and less rewarding in recent decades. Increasingly transactional care focused on addressing single conditions has enhanced the care of those conditions, but it has reduced the humanity of interactions.

GP DiTs and established GPs referred to the burden of bureaucracy, including the burden of assessment, and to the need “to increase positivity and joy in primary care working”. They also advocate supporting GP DiTs “to bring enthusiasm and innovation into an area that can often focus on the negative”.

GPs, GP DiTs and patients consistently spoke about examples of good practice, and of an ethos of providing high quality, holistic and compassionate care to individual patients and local populations. They also talked of the value of continuity of care for patients, and of  its value to GPs. Academic evidence demonstrates that continuity of care improves patient satisfaction (Fan, et al., 2005) (Adler, et al., 2010), improves quality of care (Youens, et al., 2021) (Delgado, et al., 2022) reduces hospital admissions (Barker, et al., 2017) and generates many other benefits.

GP educators expect the move to 24 months in general practice to enable longer placements and the development of care relationships with patients during the placement. In contrast to disease-focused models of care and training, respondents advocated for increased training in whole-person (holistic) care and personalised care.

A first-year GP DiT in a place-based pilot in the North West spent three days each week at a practice, and the other two days of the week in specialist rotation. In feedback, the trainee reflected: “I’ve learnt so much by training in primary care. In a hospital placement you would see very unwell people, but we wouldn’t be managing those people in the community. That wouldn’t help me understand how to stop people getting to that stage. In the community I’ve learnt how to catch things early and avoid hospital admissions.”

As part of a place-based pilot in the South East, GP DiTs spent two days per week in general practice, two days per week in a specialty such as frailty or paediatrics, and one day per week in GP education time. Trainees spent ST1 and ST2 rotating to a new practice every eight months and to a new specialty every four months, and participants enjoyed forging strong relationships with trainers, experiencing continuity with patients, and gaining an understanding of local pathways while benefiting from a balanced working life.

Priorities and action

Through the GPST reform programme, we will:

• Adopt the Enhance programme as it applies to GPST, ensuring that Generic Professional Capabilities are satisfied;
• Work with Enhance programmes locally to develop the experiences available to those on enhance programmes and to GP DiTs;
• Support the development of GP-focused Enhance trailblazers;
• Adopt longer placements to enable GP DiTs to better understand patients, families and carers, and communities.

Additionally, a pilot of blended learning placements for GP training will augment clinical work and cover core and personalised areas of learning and experience identified as priorities by stakeholders. These placements have the advantage of enhancing capacity in clinical workplaces. A bespoke empirical pedagogy has been created that includes links to the humanities, simulation, leadership, social accountability and quality improvement. Modules have already been created that support learning in several areas identified as priorities in this report, including:

• business and partnership;
• cancer diagnosis;
• digital health;
• equality, diversity and inclusion;
• leadership;
• learning disability and autism;
• mental health;
• population health and health inequalities;
• planetary health.