This was a BMAT question a few years ago. The answer is of course – both. I was reminded of it by articles and letters in this week’s The Times. Mathew Parris [a feature writer] had previously written that the ‘gatekeeper role’ of the GP is outdated and that patients should be allowed to refer themselves directly to specialist. He has since been sitting in GPs surgeries and concedes that this would not work because specialists would simply be inundated. However he still believes that most of our work could be done by others not as qualified and scientifically trained. A pilot wrote in to say that a GP’s work was very much like his – 90% routine and 10% of it requiring advanced specialist skills. A GP replied that he had ‘nothing like an autopilot for the 90% of his work.’ The GP of course knows his work well.

Mathew Parris like many management consultants entirely ignores the ‘art of medicine. I am proud of the scientific basis of my job, the application of evidence based medicine and rigor of scientific logic but a consultation with a GP often involves a lot more than making a diagnosis and treating. The ‘art’ of medicine renders all appointments interesting and none of them routine. A good doctor-patient relationship and the development of trust is therapeutic in itself. Patients are much more likely to follow advice and treatment. We are familiar with the term ‘the doctor as the drug’. A doctor’s reassurance has been shown to reduce pain scores, panic attacks and other conditions even if no treatment is given. In General Practice, where we see patients with many different conditions over a long period of time, even visits for minor conditions can augment this relationship where communication skills, sensitivity and empathy all play their part, often subconsciously.

I am reminded of the story of a team of management consultants who were asked to make efficiency savings for an orchestra. They saw that there were a number of violins all ‘doing the same job’ and cut the violins down to one. Then they started to look at other instruments. More and more cuts followed. At the end they had replaced the entire orchestra with a CD player – it did the same job and cost less didn’t it?  But of course something was lost!