Dear Generalist…changing cultures and attitudes in accountable care

Guest blog by @docant
Dear Generalist… 

Amongst all the talk of Accountable Care Systems within an STP environment and deconstructing the internal market and all that jazz: one of the key things that keeps getting mentioned is about changing cultures and attitudes.


We discuss it in terms of changing the ‘system’s’ view of General Practice: realising its value in addressing health inequalities and helping reduce overall system spend. Lots of hope that true investment will follow.

We fervently discuss cultural change when discussing the closer integration between primary and community care services and secondary care services. Hard to argue with that too much.

But it occurred to me during a discussion regarding behaviours within the hospital system that there’s one behavioural change we never discuss.

 This was lightbulb moment I had during a conversation with our  DPH  Greg Fell. (Some say he’s the new Muir Gray you know!)


………… So, we’re there discussing increasing super/sub specialisation in our hospital sector and how regional networking of hospital services in our STP future will accelerate this. We were lamenting how a consultant will often refer on to another speciality if another problem outside of their own rears its head and how they don’t call upon the patients GP when I hit upon the truth.

If we are to accept that GP’s are the last bastion of true general medicine and the home of the vast majority of contacts and interventions in the NHS. If GP’s are the diagnostic and management common sense specialists then there is one bit of cultural and behavioural change that must follow.

 GP’s will ring consultant specialist colleagues for advice. It can be the patient’s own consultant they are already under or it could be the on call registrar for advice in a more acute scenario. It’s sensible, it can avoid unnecessary referral or even admission. It can ensure the right diagnostic test is ordered. It can often just reassure the generalist that their instinct to do watch and wait was right. It can also reassure the patient.

It’s a fairly ingrained cultural thing on both sides that this behaviour happens. Nobody questions it. Everyone feels the value.


So here’s the thing:


I’ve been a partner in my practice for over 15 years with some other years in GP land before that and I have never…. ever…..genuinely….. been called by a specialist for advice.

So why don’t we change that? Why doesn’t a sub-speciality consultant faced with complex multi-morbidity call the generalist for a word of advice or reassurance?

Now before any GP’s that are reading this start whinging about being swamped or this being unpaid work think how little you actually call on a busy consultant colleague to give you unpaid advice. I think we would be called occasionally and appropriately once we give our colleagues permission to do so.


What would the benefits potentially be?

Well we know our customers. We may be able to contextualise a patient to the specialist so they understand the patients view about the Northern General. (husband died there)

We might be able to head off some overtreatment and polypharmacy problems before they occur. (very likely)

We might be able to reassure that Edith will be able to continue living at home despite her poor mobility and the place being an infection control nurses worst nightmare because we are aware it’s been like that for decades and she’s survived this long. (definitely)

We will on occasion be able to bring our renowned whole person care common sense to play and act in the patient’s best interest. (“don’t do that Mike, you have to think of her as terminally ill now, stop the drug, refer to palliative care…”)

Potentially this is a cost nothing quid pro quo we should be encouraging in our new joined up accountable care systems that has enormous impact improving satisfaction, preventing harm and yes, reducing cost.

All the best ideas are simple I’m told!




Dr Anthony Gore, GP, Clinical Director, NHS Sheffield CCG


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