General practice has four fundamental roles that allow the health system to operate effectively and efficiently. First, GPs acknowledge uncertainty and manage risk. In contrast to hospital practice, there is a low probability of disease in patients seen in general practice. It has been estimated that more than 60 per cent of presentations in general practice cannot be explained in terms of recognized disease processes, although the attention of policy makers has focused on the 40 per cent that can. This does not mean that GPs are doing something unimportant. From a patient perspective, excluding cancer and providing reassurance is as important as diagnosing and treating cancer. So too is using clinical judgement to decide that a child with a fever probably does not have meningitis. If GPs referred all people with potentially dangerous symptoms and signs to hospital, hospitals would implode in weeks. Cooperation between generalists and specialists ensures that risk is managed appropriately for the patient.
Second, GPs manage the interface between professionalized care and self-care. Self-care of the symptoms and signs of ill health is infinitely more common than care provided by health professionals. Minor changes in people’s help-seeking behaviours can have a massive impact on the use of scarce health care resources. There are therefore practical as well as philosophical reasons for encouraging a high level of cooperation between patients and their GPs, promoting shared care and informed self-management, particularly for people with long term conditions. Promoting self-care effectively requires the deep understanding that GPs have of patient’s health beliefs and the environment that they live in, as well technical expertise in encouraging behaviour change. GPs are essential if policies promoting shared and self-care are to be delivered.
Third, GPs recognize and manage the up-stream determinants of health, whilst specialists focus primarily on the consequences of those determinants. The environmental and behavioural determinants of ill-health, such as poor housing, unemployment, diet, exercise, and stress, are widely recognized but highly resistant to remedial action. As members of the communities that they serve, GPs have a deep understanding of what needs to be done as well as having the trust of patients to lead change. General practice is public health with a personal touch and, again, cooperation lies at the heart of effective and efficient care.
Lastly, GPs manage the tensions inherent in the multi-dimensional approach to quality. Hospital specialists rightly focus on the clinical effectiveness and safety of the care that they provide – this is what patients want and need when they go to hospital. But someone in the health system needs to maintain a balanced view of quality, managing what are sometimes trade-offs between good clinical outcomes and waiting times, between providing safe care and containing the costs of minimizing risk, between meeting the preferences of individuals and ensuring fairness to everyone. Taking responsibility for these trade-offs is neither easy nor popular, but GPs do it effectively every day on behalf of the wider health system.