Constructing the environment of the doctor–patient interaction in general practice

General practice culture

The gulf between the practice of medicine in hospitals and in the community is particularly deep in the UK. This gulf was institutionalised by the creation of the National Health Service (NHS) in 1948: hospital doctors became state employees but general practitioners (GPs) retained their independent contractor status and this had a profound and enduring effect on the culture of general practice.

General practitioners practise medicine in the community while at the same time running a small business. This will be a familiar tension to groups of private specialists, but not to most hospital consultants or juniors. Thus GPs typically work in partnerships that employ other staff, such as nurses, receptionists, clerical staff and practice managers. The local primary care trust (PCT) pays gross sums to the partnership as determined by the size of the practice, whether various targets are reached and what additional services are provided. The partnership must then pay their staff, provide premises if they choose to practise from their own building, and pay all other costs. The profits then remaining are divided between the partners as they themselves have determined in the partnership agreement.

General practice is carried out at a cottage industry scale, rather than the typical industrial scale of activity of the average hospital. GPs tend to be professionally embedded in their communities, and practise a form of medicine that consciously embraces a biopsychosocial model, both of pathology and of care. They may know their patients and their patients’ families as their lives unfold together over decades. GPs form one part of the wider primary healthcare team, which also includes healthcare workers employed directly by PCTs and other bodies, for example health visitors, community nurses, community occupational therapists and family planning clinic doctors.

General practitioners therefore tend to be both holistic and individualistic, and have a practical concern both for patients and for business. They consider their independence to be in their own and their patients’ best interests. When UK general practice works well, it is rightly valued as a world-class model for primary care medicine. But, as with any large group of small individualistic bodies, there is also plenty of scope for things to go wrong and perhaps also remain hidden.