Could generalists lead the war against excess in the NHS?

Generalism can help patients choose what they want and understand the risks and benefits of treatments
older patient receives care
'Multiple chronic diseases are the new normal, especially in an ageing population.' says Steven Lewis. Photograph: Alamy

Specialisation is a consequence of the expansion of knowledge. In healthcare it is considered proof of disciplinary maturity and excellence in research and practice. It has led to more effective treatments for serious diseases. It has also eroded the status and role of the generalist. But there is a paradox: the safety and quality of healthcare remains uneven. Producing new knowledge is, evidently, much easier than translating it into better care. Could the pendulum have swung too far in the direction of specialisation?

Patients often complain of multiple chronic diseases, the new normal, especially in an ageing population. What is optimal care for a single condition, often becomes a risk factor in the presence of other conditions and therapies. Drugs that subdue abnormal physiological measures may make everyday life a little more miserable. Quality of life goals may be more important to patients than submitting to every conceivable attempt to defy decline and death.

There is increasing recognition of these realities and a consequent renewal of interest in generalism. The central idea is that patients need holistic and continuous care. That should be the job of a primary care system capable of dealing with this complexity and keenly attuned to the preferences of patients. There will be a need to consult with and refer to specialists, but the main locus of care should be the primary care team. By international standards the NHS has been a leader in primary care enhancement and nurse-led chronic disease management in the community.

These developments raise an important question. Is the purpose of generalism to do what is now done, only in a more co-ordinated fashion and perhaps more cost-effectively, or is it to do things differently? It seems clear that a more robust, well-supported generalism simplifies care for patients, reduces the risks of poor communication and conflicting advice among providers, and increases prospects for a genuine partnership with patients. These are self-evidently desirable as long as generalists recognise what they don't know and enlist specialists when they need to. Given the cultural bias that equates specialisation with excellence, the risk of false positive referrals remains far greater than a generalism whose reach exceeds its grasp.

A more intriguing aspect of a new generalism would be to do things differently. Healthcare is fond of military metaphors: diseases strike; bodies are invaded; we declare war on cancer; we fight insomnia. The imperative is to counter aggression with superior force, a medical arms race against nature's indifference to individual suffering and the inevitability of decline and death. Accommodation and acceptance are in this view defeatist; it is our moral obligation to rage, rage against the way of all flesh.

Perhaps we are seduced by an overly optimistic framing of the issues, and generalism may supply the needed corrective. Quality experts appear to have reached a provisional consensus that about 30% of care in rich countries is either useless or harmful. The elderly consume staggering amounts of drugs, many combinations of which land them in hospital. Skyrocketing CT use and its attendant radiation exposure causes a good deal of cancer.

Generalism can help patients articulate their own preferences, understand the risks as well as benefits of treatments, and exercise reasonable scepticism where warranted. Healthcare is a combination of science, hope, and hype. It will gobble as much of the GDP as we are prepared to lavish upon it. We need to fight the war against excess, and that war may be best led by the generalists. The results would be more patient-centred care and quite possibly, lower costs. It's an option well worth pursuing by the NHS.

Steven Lewis is adjunct professor of health policy at Simon Fraser University in Canada; he will be speaking at the Nuffield Trust Health Policy Summit on 7 March.
