Dismantling Lord Moran's ladder: the primary care expert generalist.

1 It is over 50 years since Lord Moran suggested that GPs were doctors who have fallen off the specialist ladder. 2 Then, two-thirds of early career GPs would have preferred to have been specialists. 2 Today Lord Moran's ladder lives on. General practice is still not a first career choice for many graduates, certainly not enough to sustain the workforce we need. 3 Our conversations with early career medics reveal that they value the opportunities for flexible working within general practice. But also that they want 'something more' than the GP role: notably, opportunities to develop 'special interests'. We suggest this represents a failure to recognise, or value, the specific expertise of the GP role itself; and in particular a misunderstanding of the primary care expert generalist approach. THE PRIMARY CARE EXPERT GENERALIST We start by considering what we understand by the expert generalist. The role is defined by two elements. First, a principle of personalised decision making which recognises health as a resource for living and not an end in itself. 4 Second, it is the practice of interpretive medicine: the critical use of a range of knowledge in a dynamic exploration and interpretation of individual illness experience. 5 (Knowledge includes the biographical and biotechnical, as well as that derived from professional experience.) Crucially such expertise includes the capacity to judge the trustworthiness of the interpretation. 5 Thus, we can distinguish between the specialist who offers solutions (and may indeed re-frame problems to fit their solution), and the generalist who helps to 'define the problem'. 6 However the wider literature highlights two differing views of the generalist, as a 'jack of all trades' and as practitioners with an 'acquired expertise'. 6 The former 'all-rounder' view of the generalist GP is widespread both within and outside the profession. In interviews with local GPs, many described generalist practice as 'knowing a little about a lot, rather than a lot about a little'. This is reflected in health service managers' view of generalists as having capacity to take on an ever broader range of care, including the flexibility to plug gaps in the system. Generalists become defined by their range of work, rather than by their expertise. The failure to recognise, or value, generalist expertise in turn contributes to the creation of technical systems to support 'non-specialists' in delivering 'expert' care. As ever more (specialist) health care is moved into the …