General Practice: Primary care, the NHS and the consultation

🩺 Primary care, the NHS and the consultation. About 9 in 10 NHS patient contacts happen in primary care, and most problems start and finish there. General practice is defined by first-contact, continuous, comprehensive and coordinated care for registered patients, managing undifferentiated illness and uncertainty with limited time and tests. This chapter covers how UK primary care is organised, how a GP consultation works, referral and prescribing, and the skills examined in the UKMLA (CPSA) and MRCP.
Your four questions for every primary care consultation: Why has this person come today (their ideas, concerns and expectations)? Is there anything that must not be missed (red flags)? What is the shared plan, and does the patient agree? What is the safety net - what should make them come back, how and when?

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How UK Primary Care Is Organised

• General practice is the entry point to the NHS: patients register with a practice, which holds their lifelong (Lloyd George and electronic) record. In England there are about 6,000 practices with an average list of roughly 10,000 patients.
• Gatekeeping: most specialist care is accessed through GP referral, which protects patients from over-investigation and keeps hospital care for those who need it. Self-referral routes exist for sexual health, maternity, physiotherapy (in many areas), talking therapies (NHS Talking Therapies), audiology and some others.
• Integrated care systems (ICSs) - the 42 ICSs in England, each with an integrated care board (ICB), plan and commission most local NHS services, including general practice, under the Health and Care Act 2022.
• Primary care networks (PCNs) - groups of practices covering about 30,000–50,000 people that share staff and services (e.g. pharmacists, social prescribers) and deliver extended-access appointments.
• Out-of-hours care: NHS 111 (phone and online), GP out-of-hours services, urgent treatment centres and Pharmacy First (community pharmacists can supply treatment for seven common conditions, e.g. uncomplicated UTI in women 16–64, sore throat, sinusitis, impetigo, infected insect bites, shingles and acute otitis media in children 1–17).
• Devolved nations organise care differently (e.g. health boards in Scotland and Wales; combined health and social care trusts in Northern Ireland), but the principles of registered-list general practice are the same.
• Regulators and bodies: GMC (doctors), CQC (inspects practices in England), RCGP (training, MRCGP), NICE (guidance), MHRA (medicines safety), UKHSA (health protection).

The Primary Care Team

Role	What they do
GP (generalist)	Undifferentiated and complex problems, diagnosis, multimorbidity, prescribing, certification, leadership of the clinical team
Practice nurse	Chronic disease reviews, cervical screening, immunisations, wound care, contraception
Healthcare assistant	Phlebotomy, BP, ECGs, NHS Health Checks, new patient checks
Clinical pharmacist	Structured medication reviews, polypharmacy, long-term condition prescribing, medicines reconciliation after discharge
Physician associate / ANP	Same-day and minor illness work under GP supervision (scope set locally; supervision and accountability must be clear)
First-contact physiotherapist	Musculoskeletal problems without GP referral
Social prescribing link worker	Connects people to community, financial, housing and activity support - addresses non-medical drivers of ill health
Care coordinator / health coach	Personalised care planning, care homes, frailty
District and community nurses	Housebound patients, palliative care, wounds, catheters
Health visitor and midwife	Under-5s, new birth visits, child development; antenatal and postnatal care

• Many of these roles are funded through the Additional Roles Reimbursement Scheme (ARRS) via PCNs.
• Know the limits of each role - escalation routes, supervision, and who holds clinical responsibility are core professionalism topics.

Contracts, QOF and Quality

• GMS/PMS contracts - practices are independent contractors paid largely per registered patient (global sum, weighted by the Carr–Hill formula for age, deprivation and workload), plus enhanced services and quality payments.
• Quality and Outcomes Framework (QOF) - a voluntary pay-for-performance scheme with registers and indicators for long-term conditions (e.g. BP targets in hypertension, HbA1c in diabetes, statins in CVD). Personalised care adjustments (formerly "exception reporting") remove patients for whom an indicator is inappropriate.
• Enhanced services - e.g. childhood and adult immunisations, care home support, extended hours.
• Quality improvement in practice: significant event analysis (SEA), clinical audit, prescribing audits, patient surveys (GP Patient Survey), Friends and Family Test, complaints, learning from patient safety events (LFPSE).
• Pitfall: QOF targets apply to populations, not individuals - always balance a target against frailty, life expectancy and patient priorities.

Consultation Models

Model	Key idea
Stott and Davis (1979)	Four potentials in every consultation: management of presenting problems, modification of help-seeking behaviour, management of continuing problems, opportunistic health promotion
Pendleton (1984)	Seven tasks including reason for attendance, other problems, choosing an action, shared understanding, involving the patient, using time and resources, maintaining the relationship
Neighbour - The Inner Consultation (1987)	Five checkpoints: connecting, summarising, handing over, safety-netting, housekeeping (the doctor's own state)
Calgary–Cambridge	Initiating the session → gathering information → physical examination → explanation and planning → closing; structure and relationship-building run throughout
Helman's folk model	Patients ask: What has happened? Why me? Why now? What would happen if nothing were done? What should I do?
Biopsychosocial (Engel)	Illness reflects biological, psychological and social factors - consider all three

• The CPSA (UKMLA clinical exam) and MRCGP CSA/SCA reward patient-centred structure: open start, active listening, ICE, summarising, clear explanation, shared plan, safety net.

Ideas, Concerns and Expectations

• Ideas - "What do you think might be going on?"
• Concerns - "Is there anything in particular that worries you?" (often cancer, a relative's illness, or loss of work)
• Expectations - "What were you hoping we could do today?"
• Exploring ICE reduces unnecessary prescribing (e.g. antibiotics for viral illness), improves adherence and avoids the "by the way" (doorknob) problem.
• Also explore impact (work, sleep, caring roles) and the hidden agenda - the presenting complaint may be a "ticket" for something more difficult (low mood, domestic abuse, sexual problems).

Core Skills - History, Explanation and Shared Decisions

• Golden minute - let the patient talk uninterrupted at the start; most finish within 1–2 minutes.
• Cues - verbal and non-verbal; pick them up and reflect them ("You mentioned your father…").
• Targeted history and examination - in 10–15 minutes you cannot do everything; focus on discriminating questions and red flags.
• Explanation - chunk and check: give information in small pieces, check understanding (teach-back), avoid jargon, use diagrams or written leaflets.
• Risk communication - use natural frequencies ("4 in 100 people") rather than relative risks; visual aids (e.g. icon arrays); include the risk of doing nothing.
• Shared decision-making (NICE NG197) - discuss options including no treatment, benefits, harms and the patient's values; the BRAN prompt: Benefits, Risks, Alternatives, what if I do Nothing?
• Time as a tool - "watchful waiting" with planned review is legitimate when red flags are absent.
• Consent and capacity - assume capacity; assess decision-specifically (Mental Capacity Act 2005) when in doubt.

Safety-netting and Follow-up

• Safety-netting = explaining what symptoms should prompt the patient to seek help, how urgently, and how.
• Make it specific: "If your child becomes floppy, has a rash that does not fade under a glass, or is not drinking - call 999 or go to A&E" - not "come back if worse".
• Include expected course ("a cough often lasts 3 weeks"), when to return if not better, and who acts on results (and how the patient will be told).
• Document the safety-netting advice given.
• Diagnostic safety-netting for possible cancer (NICE NG12): ensure follow-up of patients with low-risk-but-not-no-risk symptoms; track urgent referrals and results.
• Continuity - seeing the same GP is associated with lower mortality, fewer admissions and higher satisfaction; arrange follow-up with the same clinician where possible.

Remote and Total-triage Consulting

• Many practices use total triage: online or phone requests are reviewed and patients are directed to the right clinician and modality (phone, video, face to face, pharmacy).
• Remote consultations are unsuitable or need conversion to face to face when examination is needed, the patient is very unwell, there are communication barriers, or there are safeguarding concerns.
• Risks: missed non-verbal cues, inability to examine, identity and confidentiality issues, digital exclusion (older, deprived, non-English-speaking patients).
• Good practice: confirm identity and location (for emergencies), check who else is present, use a lower threshold to see in person, and safety-net clearly.
• Remote prescribing - GMC guidance: only prescribe if you have enough information to do so safely; extra caution with controlled drugs and medicines liable to misuse.

Challenging Consultations

• Breaking bad news - SPIKES: Setting, Perception, Invitation, Knowledge (warning shot, plain language), Emotions (acknowledge, silence), Strategy and summary.
• The angry patient - acknowledge, listen, apologise for the experience where appropriate (the duty of candour applies if harm has occurred), avoid defensiveness, agree a plan; maintain safety (chaperone, alarm, end the consultation if threatened).
• Requests you cannot meet (e.g. antibiotics for a viral illness, a sick note without illness, benzodiazepines) - explore ICE, explain your reasoning, offer alternatives, and remain respectful; you are not obliged to provide treatment you believe is not in the patient's interest.
• Interpreters - use professional interpreters, not family (especially not children) for clinical or sensitive discussions; allow double time.
• Medically unexplained symptoms / persistent physical symptoms - validate the symptoms as real, avoid repeated investigation without new features, agree a named clinician and regular scheduled reviews, explore psychosocial factors, consider talking therapies.
• Frequent attenders - look for unmet need, depression, anxiety, social problems and undiagnosed disease; a regular planned appointment often reduces unplanned use.

Referral, Advice and Guidance

• Routine referral - via the NHS e-Referral Service (e-RS); include the question being asked, relevant history, examination, investigations, medication and patient preferences.
• Advice and Guidance (A&G) - asynchronous specialist advice without a referral; avoids unnecessary outpatient appointments.
• Urgent suspected cancer referral (NICE NG12) - for symptoms meeting criteria; in England the 28-day Faster Diagnosis Standard (diagnosis or exclusion within 28 days) and 62-day treatment target apply. Explain to the patient why they are being referred (some may have cancer) and safety-net.
• Same-day/acute referral - via the medical, surgical or paediatric on-call team (e.g. ambulatory care, SDEC).
• Direct-access investigations - many tests can be ordered by GPs directly (e.g. FIT, CXR, echo for suspected heart failure with raised NT-proBNP, CT abdomen in specific cancer pathways, non-urgent endoscopy).
• A good referral letter answers: Who? What is the question? What has been done? How urgent? What does the patient know and want?

Prescribing in Primary Care

• Repeat prescribing - most items are repeats; safe systems need regular medication reviews, monitoring (e.g. U&E with ACE inhibitors, LFTs with methotrexate) and clear authorisation.
• Structured medication reviews (SMRs) - prioritise people with polypharmacy, frailty, care home residents and those on high-risk drugs (e.g. opioids, anticoagulants, anticholinergics).
• Shared care agreements - specialist initiates and stabilises; GP continues with defined monitoring (e.g. DMARDs, lithium, ADHD medicines).
• Antimicrobial stewardship - delayed (back-up) prescriptions, TARGET toolkit, NICE antimicrobial guidelines (e.g. NG84 sore throat with FeverPAIN/Centor scores, NG120 cough, NG109 UTI).
• Controlled drugs - prescription requirements (Schedule 2 and 3): total quantity in words and figures, dose, form, strength; normally up to 30 days' supply.
• Generic prescribing - preferred, except where brand matters (e.g. some antiepileptics, ciclosporin, tacrolimus, MR theophylline and lithium).
• Free prescriptions in England for people aged under 16, 16–18 in education, 60 and over, pregnant and up to 12 months postpartum (maternity exemption certificate), and those with specified conditions (medical exemption certificate - e.g. diabetes on medication, hypothyroidism, epilepsy, cancer). Prescriptions are free in Scotland, Wales and Northern Ireland.
• Prescription prepayment certificates (PPCs) reduce costs for those paying for many items.

Records, Results and Continuity

• Coding (SNOMED CT) enables registers, recalls and audit - code diagnoses accurately.
• Results management - every result must have a named clinician who files it and an action; patients should know how results will be communicated.
• Summary Care Record / shared records - allow urgent care settings to see medication and allergies; patients can opt out.
• Patient online access - patients in England can see their GP records online; write clearly and accurately, and be aware of third-party and safeguarding information.
• Confidentiality (GMC) - disclose only with consent, where required by law, or where it is justified in the public interest (e.g. serious crime, risk of serious harm).

Primary Care at a Glance

Topic	Remember
Organisation	ICB → PCN → practice; registered list; gatekeeping
Pay and quality	Global sum (Carr–Hill); QOF; enhanced services; CQC inspection
Consultation	Open start, ICE, cues, summarise, explain, share decisions, safety-net
Neighbour	Connect, summarise, hand over, safety-net, housekeeping
Stott and Davis	Presenting problem; continuing problems; help-seeking; health promotion
Referral	e-RS, A&G, urgent suspected cancer (28-day FDS), SDEC
Prescribing	SMRs, shared care, antimicrobial stewardship, CD requirements

Spot the Answer

• A patient's last line as they reach the door is "by the way, I've been passing blood". → The doorknob phenomenon - always ask "Is there anything else?" early, and take the new symptom seriously.
• Which consultation model includes "housekeeping"? → Neighbour's Inner Consultation.
• A practice audits how many patients on methotrexate have had blood monitoring in the last 3 months. → Clinical audit (measuring against a standard).
• A woman of 28 has dysuria and frequency; the practice is closed. → Pharmacy First can treat uncomplicated UTI in women aged 16–64.
• Who funds and plans general practice services locally in England? → The integrated care board (ICB).

Exam-style Scenarios

• Scenario. A 45-year-old man requests antibiotics for a 4-day cough with clear sputum. He is afebrile with normal observations and a clear chest. He says his wife insisted.
  Answer: Explore ICE (fear of pneumonia; time off work). Explain that most acute coughs are viral and last about 3 weeks, that antibiotics make little difference and cause side effects, and offer self-care and a safety net (breathlessness, chest pain, coughing blood, high fever, symptoms beyond 3 weeks). A back-up prescription is an option only if there is a specific concern (NICE NG120).
• Scenario. A 70-year-old woman attends for the third time in a month with fatigue; tests so far are normal. She mentions her husband died 6 months ago.
  Answer: Pick up the cue - explore grief, low mood, sleep, appetite, alcohol, loneliness and suicidal thoughts. Screen for depression (PHQ-9), review examination and red flags (weight loss, new symptoms), consider bereavement support or social prescribing, and agree regular follow-up with the same GP.
• Scenario. During a telephone consultation a mother describes her 9-month-old as drowsy, with a rash and reduced feeding.
  Answer: Convert to an emergency response: advise 999/immediate assessment (possible meningococcal sepsis) - do not try to complete the assessment by phone. Document the advice and timing.
• Scenario. An FY2 in general practice sees a patient with new rectal bleeding aged 62. What should the referral include and what must the patient be told?
  Answer: Request FIT (if not already done) and refer on the suspected lower GI cancer pathway if criteria are met; tell the patient why (to rule out cancer), when they should hear, and to call if they do not; document and track the referral.

Key Points

• General practice manages uncertainty: careful history, red flags, time, follow-up and safety-netting.
• ICE, cues and shared decisions are central to the consultation and are explicitly assessed.
• Safety-netting must be specific and documented.
• Continuity of care improves outcomes.
• Every result and referral needs an owner and a tracking system.
• Know the roles in the wider team and their limits.

Guidelines and Further Reading

• NICE NG197: Shared decision making
• NICE NG12: Suspected cancer - recognition and referral
• NICE NG120 (cough), NG84 (sore throat), NG109 (lower UTI) antimicrobial prescribing guidelines; RCGP TARGET antibiotics toolkit
• GMC: Good medical practice (2024); Decision making and consent; Confidentiality; Good practice in proposing, prescribing, providing and managing medicines and devices
• RCGP: Curriculum and MRCGP SCA guidance
• Neighbour R. The Inner Consultation (1987); Silverman, Kurtz and Draper: Skills for Communicating with Patients (Calgary–Cambridge)
• NHS England: Pharmacy First service specification