PI Brief Update

Understanding GPs: Biopsychosocial Progress - Dr Mark Burgin

27/12/19. Dr. Mark Burgin BM BCh (oxon) MRCGP discusses a novel way of measuring GP effectiveness based upon the Biopsychosocial Model BPSM.

It is difficult to see how GPs can cause any impact upon health as they rarely arrange complicated tests or perform surgical procedures.

GPs have been described as gatekeepers to secondary care which suggests that GP performance can be measured on their ability to choose the right patients to refer.

Although high referring practices are often poorly performing based upon a range of measures the patients that they refer are sicker.

This goes against the belief that the GPs are referring patients who should not be referred because it seems obvious that sick people should be seen in secondary care.

The Biopsychosocial Model

The Biopsychosocial Model BPSM is based upon the idea that a medical diagnosis does not provide the complete picture of the patient.

Specialists look for clarity and simplicity and powerful treatments whilst GPs prefer subtlety and complexity and the long game.

GPs consider social and psychological causes as well as biological causes which allows them to identify all their patient’s risk factors.

GPs are the experts in assessing complex and apparently insoluble problems, but do they do more than just prevent patients from seeing specialists?

Aesop's The North Wind and The Sun

Specialist are like the North Wind, they have powerful approaches that can knock down the barriers in their way and cost a lot of money.

GP are like the sun (in northern Europe), they can make things more pleasant but cannot knock down walls or transform the landscape.

This inability to create change should not be seen as weakness because like the sun making the man want to take off his coat when the wind cannot blow it off, GPs can be persuasive.

Over time a specialist’s work can be undone by a patient’s resistance whereas a GP’s work becomes more effective by reducing risk factors and therefore preventing illness.

Why do GPs have a reputation as the poor relative of hospital medicine?

General Practitioners struggle to describe why their care approach works at all and are reluctant to claim that prevention is better than cure.

Research from Professor Jarman and Barbara Starfield have shown that use of the BPSM in a health care system gives better outcomes for total health.

Henningsen’s criticism that little research has been undertaken to understand and explain why the BPSM is effective gives one possible explanation for GPs poor reputation.

The current implosion of General Practice (falling numbers and GMC report) means that any progress in improving the status of GPs is unlikely in the near term.

How do GPs keep patients healthy?

Rather than having a limited set of targets ‘good control’ GPs use aims based upon many biopsychosocial targets that are agreed with the patient.

The biopsychosocial target might be to address a social problem like housing or improve mental health rather than for instance just improving the chronic disease control.

In some ways biopsychosocial progress is straight-forward as the larger the number of aims agreed, the more likely it is to achieve any one of them.

Reducing biopsychosocial risk factors for poor health is Biopsychosocial progress and an increased likelihood that the patient will stay well.

Conclusions

GPs underestimate the effectiveness of the biopsychosocial model in achieving extraordinary outcomes and forget the old adage that prevention is better than cure.

By addressing what their patient thinks are problems and setting multiple biopsychosocial (BPS) targets the patient achieves ongoing Biopsychosocial Progress.

It is possible to measure Biopsychosocial Progress by documenting the BPS targets and the progress made against them.

This novel measure of GP effectiveness promises to improve GPs status as specialists of complexity and allow managers to move from short term ‘good control’ targets.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register and audits medical expert reports.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502.

Henningsen P. Still modern? Developing the biopsychosocial model for the 21st century. J Psychosom Res. 2015;79:362–3

Jarman 1999 Explaining differences in English hospital death rates using routinely collected data BMJ 1999 318:1515

Image: public domain from https://pixabay.com/en/doctor-medical-medicine-health-563428/