General practice: changing problems, enduring values

In recent months, much has been written about the challenges facing contemporary general practice: some worrying, some reassuring. But, pegs to hang some coats on. Two texts to start with: ‘Times change, and we change with them.’ 1 ‘The more things change, the more they are the same.’ 2 These days, new initiatives to improve the clinical process are rarely underpinned by theory. They tend to over-claim potential benefits, and to underestimate dis-benefits. Twenty years ago it was the internal market and fund-holding. Then evidence-based medicine was hijacked by devotees of the randomised clinical trial (RCT). It became inevitable that the evolution of guidelines, targets, and incentives would be inappropriately directive, lacking as they did sufficient acknowledgement of the importance of patient variables and of the context in which consultations take place. The Quality and Outcomes Framework (QOF) followed. And the next phase may be a world dominated by IT in one form or another.3,4 One important role of academic medicine is to try to establish the best available theoretical basis for clinical practice. This reflection centres on the consultation, still widely seen as …