In the UK, much of the progress in general practice over the recent past has evolved in the context of group practice and the primary health care team the credo of modern-day doctoring. Single-handedness puts a question mark over the primacy and validity of these ideas. The benefits of highly ordered, management-led, high-investment, team-based general practice are real and not to be gainsaid; larger practices may also have easier rotas, with possible benefits to the mental health of GPs. But at what price have these benefits been bought? Can small be beautiful?and what does this concept mean for health care the world over? Let us start with the observation that general practice is about people. Their illnesses are the incidental accidents, and their deaths the only certainties which mark the impingement of these individuals on our general practice nights and days. These emergency contacts are, for the larger practices, usually boring or worse. There is no before or after: just a job to be done. For the single-handed GP doing more of his or her own visiting, these occasions may also be boringinitially. But the utility and the interest inherent in these visits can, with continuity of care, stretch over the decades, as this example illustrates. One of us (JML) was called to an unrousable, sweating 60-year-old man, whom we admitted to hospital with suspected septicaemiawhich, years later, turned out to be the presenting symptom of an occult, indolent malignancy. We looked after him until his death at home. The continuity of care made the job interesting for us, not the clinical details. But the continuity does not stop at the end of one life. Now, whenever we see his wife, on however trivial or grave a problem, we have this shared bond. Recently she refused hospital admission for pneumonia, and the doctor could use this shared bond to induce her, over a a day or so, to change her mind. Of course, doctors in large groups will be able to tell of similar instances. Our point here is simply that these stories are more common, the more personal your care. Small practices may be best placed to counter the rising tides of paperwork, targets and guidelines now engulfing general practice.
The dangers of exhaustion and isolation in single-handed practice are real, but they are usually pointed out by people who are thinking about isolation from one's colleagues. (How many partnerships are only partnerships on paper, and conceal or exemplify worse things than isolation?) The singlehanded doctor is more likely to compensate for isolation from colleagues by identifying more with his or her patients.
As one GP has commented I am now about to start a day of singlehanded general practice as my partner is away. The day is unplanned, the appointments book empty. People just turn up, bringing their infarcts, their sorrows, their trivia, and their life events to me. Some of the people who will come have not yet even fallen ill. There are the coronary artery plaques on the point of rupturing, the dizziness before the fall, the hallucination before its enactment, and someone is now writing a note to explain the impending suicide or the fact that they are leaving home forever, and taking the kids with them. All this is in the future; but for now, none of this has happened yet. I am completely up to date, and I command my general practice sitting behind an empty desk. I saw the last person who wanted to see me yesterday. There is no waiting list. Just the unknown. And what of the concept of the primary health care team? Can it really be called a team when I own the premises, hire most of the staff, pay them their wages, draw up their job description, and stipulate the bounds of their practice? It is certainly not an equal partnership. But when the patient's dizziness does lead to the fall in the village shop, as it did yesterday, I will be on hand to patch up the old lady, and the receptionist will kindly finish off the patient's shopping for her, and escort her home. We think that the price of a personal service is well worth paying.
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