I recently chaired a panel discussion that was considering the question, “what will the infrastructure of general practice look like in 5 years’ time?”. What was most interesting about the discussion was the debate the panel had as to whether general practice could evolve quickly enough to prevent itself becoming extinct.

I didn’t expect that either. Most of us would agree with the starting point which is that we expect general practice to become bigger in the next 5 years. However, it won’t get significantly bigger. We might make it to the 20-50,000 population primary care home size, but only because that is what one panel member described as the “mentally capable” next step, i.e. the one that isn’t too far away from where we are now to feel doable. Getting to a 300,000 or even 500,000 population size, one where real economies of scale can be achieved and system leadership exerted, feels like a distant dream in most places because it is too far away from where general practice is right now.

As one panel member explained, the reason anything like this can’t happen quickly is because getting practices to work together is hard work, and takes what he describes as “hand-to-hand combat” – tackling one practice at a time. That is why getting universal population coverage at a scale of 20-50,000 is challenging, and why getting to something bigger than that is simply out of reach.

This pace of change may simply not be fast enough. For two reasons: one, the system wants to drive integration at a greater scale faster than general practice can keep up with; and two, the technological disruption we have seen from GP at Hand is likely to only be the start and it remains to be seen whether general practice in its current form can survive it.

One panel threw in the example of dinosaurs, as a telling reminder that “evolution is not mandatory”. As another said, “all innovation is a generational war, and we know who wins that one…”

Which all then led to an existential discussion about the value that general practice adds. Do we really know what it is? One GP panel member stated he is not clear which patients he adds the most value to – the data simply is not there. The starting point for general practice to move into the future is to prove the difference it makes to people, and then to do more of that.

If the primary role of general practice is the place we take our symptoms to find out what is wrong with us, won’t that at some point in the (near) future get replaced by technology? If it is to act as a gatekeeper to the rest of the system will that role continue to be accepted by the coming generations who demand instant access to everything?

In a 2015 article in the NEJM, Martin Marshall argued that in the future general practice, “will have to get the support they need to continue to provide person-centred care and to deal with the complex and delicate balance among an individual’s health, illness (the perception that something is wrong), and disease (a confirmed diagnosis). General practices will have to facilitate the increasingly important interface between people’s management of their own health and the care that is delivered in partnership with, or by, health care professionals. And they will have to find ways to negotiate the complex trade-offs among the sometimes conflicting expectations and needs of individuals, populations, and taxpayers, whose continuing support for a publicly funded health system is essential for its survival.” 10.1056/NEJMp1411429">N Engl J Med 2015; 372:893-897

I think the point the panel were making is that if general practice develops further as a place that is about compromise, about trade-offs, about individuals not getting the care they really want or need at the time they really want or need it, then extinction of general practice in its current form is a real possibility. Instead, key to the future is understanding, demonstrating and then developing the part of general practice that is genuinely value adding to individuals, their families and their local communities.

You can listen to part 1 of the panel’s discussion here. Part two will be published here on Monday 18^th June.