Balancing specialist roles with generalist responsibilities in primary care: Have we gone too far?

Waseem Jerjes ^*

• Imperial College London, London, United Kingdom

The increasing dominance of specialist GP roles is threatening the very foundaMon of primary care-Mmely access, conMnuity, and holisMc paMent management. If leZ unchecked, this trend risks fragmenMng care and exacerbaMng inequaliMes. Through a criMcal analysis of current pracMces and policies, I aim to idenMfy strategies to balance the benefits of special interest roles with the essenMal generalist responsibiliMes of GPs, ensuring that primary care remains accessible and effecMve for all paMents.-Benefits of special interest roles The integraMon of special interest roles within general pracMce has yielded significant benefits, parMcularly in terms of professional development and the quality of care provided. By pursuing special interests, GPs can enhance their professional idenMty and diversify their skill sets, fostering a more sMmulaMng and fulfilling career. This diversificaMon not only broadens clinical experMse but also helps miMgate the potenMal for professional stagnaMon, which can someMmes arise in purely generalist roles. 7,8 Furthermore, specialised knowledge in areas such as frailty, mental health, asthma, COPD, diabetes, and minor surgery has led to substanMal improvements in paMent care. GPs with advanced skills in these domains are beber equipped to manage chronic and complex condiMons, thereby improving paMent outcomes. For instance, GPs with a special interest in diabetes can provide more comprehensive and effecMve care, reducing the risk of complicaMons and hospital admissions. 9 Similarly, those focusing on mental health are beber prepared to offer early intervenMons and ongoing support, which is vital given the rising incidence of mental health issues in the UK. 10 Case studies have demonstrated the posiMve impact of these roles on paMent outcomes. In pracMces where GPs have developed special interests, paMents report higher saMsfacMon and beber management of their condiMons. [11][12][13][14] This not only enhances the quality of care but also reinforces the role of GPs as integral components of the healthcare system, capable of providing both breadth and depth in their services. Thus, the evoluMon towards incorporaMng special interests within general pracMce represents a significant advancement in the delivery of primary care.-Impact on general pracMce The growing emphasis on specialist roles within general pracMce has led to a significant reducMon in the availability of general GP appointments, impacMng paMent access to primary care. This trend can be abributed to the allocaMon of GP Mme and resources towards specialist areas, resulMng in fewer slots for general consultaMons. Studies have shown that paMents oZen experience longer wait Mmes for general appointments, which can lead to delayed diagnoses and treatment for a range of condiMons that would tradiMonally be managed efficiently by a generalist GP. 15,16 The increasing focus on specialist roles has reduced GP availability, forcing paMents to seek alternaMve care through NHS 111, urgent care centres, or A&E. Recent NHS data indicate that over 49,000 paMents waited more than two weeks for a GP appointment in the most recent reporMng period, with nearly 13,000 paMents waiMng over four weeks. This growing delay not only undermines Mmely primary care access but also increases reliance on emergency services, placing further strain on an already overburdened healthcare system. Consequently, paMents seeking care for non-emergency issues may face prolonged waiMng Mmes and fragmented care, exacerbaMng their health condiMons. 17 This shiZ places addiMonal strain on secondary care services, which are already under significant pressure, further complicaMng the paMent journey and potenMally compromising paMent safety.One of the primary concerns arising from this shiZ is the impact on paMent outcomes and safety. CondiMons that could be managed effecMvely within a primary care sefng may escalate when Mmely access to a GP is unavailable, leading to preventable complicaMons and hospital admissions. For example, a delayed management of acute exacerbaMons of chronic diseases can result in deterioraMon requiring emergency intervenMon, which not only impacts paMent health but also incurs higher healthcare costs. 18,19 ConMnuity of care, a cornerstone of general pracMce, is disrupted when paMents move between providers. Studies link strong GP conMnuity to beber adherence, fewer hospitalisaMons, and improved paMent saMsfacMon, yet increasing specialisaMon threatens this criMcal aspect of care. 20,21 The erosion of this conMnuity due to the increasing focus on specialist roles undermines these benefits, posing a risk to paMent safety and the overall efficacy of the healthcare system.To address these issues, it is imperaMve to evaluate the balance between specialist and generalist roles within general pracMce. A sustainable balance between specialist and generalist GP roles demands targeted policy reforms and workforce strategies that prioriMse both experMse and accessibility.-Balancing act: Generalist responsibiliMes vs. specialist roles Hybrid general pracMce should be redesigned in a way to keep generalist funcMons at the core of general pracMMoner acMvity. 22 As much as specialising in certain aspects is good for skill improvement and treaMng individual condiMons, evermore GPs are invesMng Mme in specialist funcMons at the expense of generalist consultaMons. The trend is resulMng in longer waiMng Mmes, disconMnuous conMnuity of care, and increased use of urgent and emergency services by paMents. Avoiding diluMon of generalist access in a creeping manner can be accomplished by structured scheduling systems providing protected Mme for generalist consultaMons. Repeated review of hybrid allocaMons can avoid disproporMonately cufng generalist availability. Secondly, rather than isolaMng specialist clinics enMrely from generalist funcMons, experMse in rouMne consultaMons can be introduced by GPs in a hybrid service without reducing paMent access to primary care service (Table 1).Changes in policies and contracts are needed in order to prevent financial and career rewards for excessive specialisaMon. 23 The current NHS payment mechanisms are predisposed towards specialist services in the form of top-ups and increased contracts, making it preferable for GPs to devote Mme to these posts. To reverse this trend, generalist consultaMons must be accorded equal status, and payment mechanisms in place to secure equal resource allocaMons for generalist and specialist work. Workforce contracts can be extended to include generalist Mme targets for GPs in hybrid posts, ensuring specialist interest work is complemenMng primary care and not subsMtuMng for it. The financial rewards must be rebalanced in favour of supporMng GPs who have a balanced hybrid career, and prevent excessive movement towards specialist posts.Workforce planning must have generalist and specialist GPs in balance in order to prevent deficiencies in primary care access. 24 Training pathways must incenMvise generalist experMse alongside specialisaMon, and reinforce paMent whole-system thinking. Structured generalist training alongside specialist training must be included in postgraduate GP fellowships, and trainees must have a twin-track mindset when graduaMng as a GP. Workforce surveillance at individual pracMce level and at PCNs can monitor trends in specialisaMon and prevent hybrid models creaMng a shortage in generalist care. By creaMng a structured hybrid workforce plan, pracMces can avoid imbalances negaMvely affecMng paMent access.CollaboraMon is instrumental in providing sustainable workload for hybrid GPs. MulMdisciplinary teamwork frameworks can distribute workload amongst GPs, pharmacist and nurse pracMMoners in a manner in which paMent need is saMsfied without imposing excessive workload on generalist clinicians. 25 Joint specialist clinics in pracMces in which hybrid GPs are pracMcing alongside specialists can complement experMse while ensuring primary care is sMll thorough. Internal referral networks in pracMces can allow hybrid GPs to use specialist skill without losing rouMne paMent engagement. Expansion in applicaMon of collaboraMon strategies ensures specialisaMon assists generalist and does not subsMtute generalist care.Balanced hybrid models can be facilitated in another way through technology. Virtual consultaMons can be facilitated by specialists in general pracMces who have a special interest without them enMrely moving out of core generalist acMvity. Triaging and joint use of electronic paMent records can enable specialists in general pracMces to contribute without enMrely moving out of general pracMce. Technologies can enable specialist input to be integrated in primary care without reducing generalist numbers in appointments, avoiding unnecessary referrals and ensuring primary care is sMll accessible.Strengthening career rewards for generalist pracMce is equally crucial in supporMng a balanced hybrid system. SpecialisaMon is abracMve for many GPs as a consequence of career structured routes, financial rewards, and improved status at a professional level. 26 Career advancement paths need to be structured in order to recognise generalist excellence in whole-person, firstcontact care in order to prevent generalist service being downgraded. "Generalist Excellence Fellowships" could provide leadership and training for GPs who choose a strong generalist commitment. RecogniMon at equal status for generalist skill as for specialist experMse would encourage rising numbers of GPs to have a balance between each.In short, PCNs should be given a greater role in managing hybrid models across pracMces. As opposed to individual pracMces compeMng to maintain generalist numbers in line, PCNs could be managing hybrid GP posts across sites to ensure generalist cover is balanced across networks. Inter-pracMce agreements could allow for movement between sites for GPs who have specialist experMse while generalist slots are sMll available. A planned system at PCN level would prevent concentraMon of specialist workload in certain pracMces and ensure paMent demand is allocated fairly. By placing hybrid models in network form, pracMces can strike a balance for clinicians and for paMents.Establishing generalist care as central to general pracMce would require reforms in structure, policies, staff, technology, and profession. A well-organised hybrid system can potenMally improve paMent access and beber saMsfy GPs. Without restraint, however, increased specialisaMon can compromise primary care accessibility. Policymakers and leaders in healthcare can ensure a sustainable system in which GPs can develop experMse but conMnue providing generalist, whole-person care if they use these strategies.The increased numbers of specialist jobs in general pracMce are symptomaMc of broader trends in healthcare as ever-greater emphasis is given to efficiency and targeted experMse. The underlying implicaMons for structure need to be subject to scruMny, though. Specialist pracMce in primary care is being marketed as a soluMon for waiMng Mmes for second-level care but lible is known about how it is shaping generalism as a core capability. Specialist GPs are adding clinical capability in some areas but at the expense of generaMng workload redistribuMon issues and quesMons about whether or not primary care is being adapted reacMvely rather than as a planned response. The issue is not increased numbers of specialist GPs but rather lack of a coherent policy context in which specialisaMon is reinforcing rather than subsMtuMng for generalist capability. Without this context, hybrid soluMons are at risk of being makeshiZ rather than planned workforce responses and thus generaMng variability in paMent access and diluMng generalist capability in the longer term.More consideraMon is involved in bringing in specialist funcMons to primary care than in designing a simple generalist versus specialist split. The modernisaMon of primary care must be acMve rather than passive in reacMon to trends in staffing and ensure specialisaMon is embedded in generalist rather than as a parallel system. Workforce planning does not sufficiently disMnguish between hybrid model build-out and potenMal diluMon of core primary care funcMons and service conMnuity and clarity in roles is at risk as a consequence. SpecialisaMon in general pracMce can be sustainable if delineaMon is properly established in training schemes, contractual agreements, and financial frameworks in avoiding increased fragmentaMon. A major fear is excessive dependency on allied healthcare professions as a subsMtute for generalist numbers and potenMally relocaMng the problem rather than closing systemic deficits.The broader issue is whether primary care is becoming more integrated or more compartmentalised in form, mirroring forms in general pracMce in general. Unless hybrid forms persist without underlying structure, there is a risk as much of restricted paMent access to generalist care as there is of a two-Mer system in primary care, in which paMent access is based upon presence or absence rather than upon flexibility in a generalist. Policymaking is not about preserving generalist funcMon but about reframing thinking about specialisaMon in primary care-not as a target in clinical progress but as a method in which generalist experMse is enriched. Workforce plans in the future must move beyond responses and establish longerterm frameworks in which funcMons are integrated in generalist forms, ensuring underlying philosophy in primary care-a comprehensive, available, and paMent-focussed service is not eroded.Healthcare systems worldwide are abempMng to balance specialist GP development with generalist care access. In Australia, the Royal Australian College of General PracMMoners (RACGP) has developed credenMaling pathways that allow GPs to specialise without reducing generalist responsibiliMes. 27 Similarly, in Canada, focused pracMce cerMficaMons in dermatology and palliaMve care enable family physicians to integrate specialist knowledge within generalist pracMce. 28 In Europe, training in general pracMMoner roles is structured with opportuniMes available for subspecialisaMon, with measures in place that allow generalist primary care as a basis in its delivery. 29 These models highlight the potenMal for structured career pathways that do not undermine primary care accessibility.. 30 -Balancing specialisaMon and workforce redistribuMon With increased specialisaMon in GPs comes a parallel growth in roles in pharmacists, nurse pracMMoners, physiotherapists, mental health workers and paramedics in primary care. Such pracMMoners are increasingly dealing with a wider range of condiMons, from prescribing treatments to structured long-term condiMon management. 31,32,33 The shiZ raises a quesMon about just how much it relieves specialist GPs' pressure or inadvertently drives towards service fragmentaMon. On the posiMve side, redistribuMng work can enhance increased accessibility to early care, parMcularly in those in need of regular follow-ups or MtraMons in treatments. But it also presents challenges, in terms specifically of care conMnuity. For paMents with mulMmorbidity, conMnuity with a single GP is vital. Increased reliance on mulMple healthcare professionals risks fragmenMng their care. Furthermore, as more specialist roles fall on GPs, that supply of available generalist appointments will be lowered, with planning in terms of manpower necessary in order to keep those paMents in contact with holisMc, complete primary care. A balanced approach that combines specialist roles in GPs with more extensive primary care teams is necessary in order to keep care coordinated and prevent fragmentaMon.In conclusion, the future of general pracMce should maintain a balance between specialist and generalist roles to ensure comprehensive paMent care. The unchecked expansion of specialist GP roles threatens the accessibility and conMnuity of primary care. Policymakers must act swiZly to develop structured hybrid roles, workforce strategies, and training reforms that support both specialist experMse and generalist accessibility. Future research should evaluate how hybrid models impact paMent outcomes, GP workload, and long-term sustainability in UK primary care. By implemenMng targeted policy adjustments, refining training programs, and improving workforce distribuMon, the healthcare system can support both specialist and generalist funcMons effecMvely, ulMmately enhancing accessibility and quality of care for all paMents.