Move Over Dr Finlay. The Future may be Dr FinlAI- or is it?

Remembering Dr Finlay

Whilst the famous Dr Finlay’s case book television programmes may be receding into the midst of time, the character has become a model for the “ideal GP”.

Invented by A J Cronin the initial TV series was screened between 1962 and 1971,

Dr Finlay is a general physician beginning his practice in the fictional Scottish town of Levenford. Initially his career would have been before the NHS was founded. In the stories he is charming and becomes well-acquainted with his patients over many years. It is thus his trademark to know them from birth to death and so provide a continuous relationship.

The main characters were Dr. Finlay, the junior partner in the practice, played by Bill Simpson, Dr. Cameron, the craggy senior partner, played by Andrew Cruickshank and Janet, their unflappable housekeeper and receptionist at Arden House, played by Barbara Mullen. The impact of the programme was such that it is reported that Cruickshank was invited to speak to the BMA’s annual dinner. Additionally, a song entitled Dr Finlay, sung by Andy Stewart enjoyed a position in the UK charts for 5 weeks!

Impact, Evidence and Concern

The series was set in the 1930s but it is noticeable that, even when it screened in the 1960s, GPs were expressing concern about it raising unrealistic expectations from patients. Its impact had considerable traction as, even in 2011, 30 years after the last episode was screened, the Daily Telegraph ran a headline reading ‘Farewell Dr Finlay: patients think GPs are rude and rich’, (The Telegraph, 5^th December 2011)!

Despite all the developments in medicine since the programme was set, the values of continuity of care and access to general practitioners still resonate with patients. They want to see a GP quickly when they perceive this is necessary but also to establish an ongoing relationship with a trusted GP. It is not just about the patient’s perceptions of care though. The Nuffield Trust’s publication from 2018[1]  sets out the benefits of continuity including outcomes, patient experience, and costs of care from continuity of care.

The Modern Dr Finlay

Delivery of the apparent nirvana where patients have instant access to “their doctor” is challenging. Let’s look at the “Dr Finlay comparators” to illustrate this:

• The average life expectancy has increased by around 20 years since Dr Finlay’s time in Levenford[2]
• Healthy life expectancy has also increased over time, but not as much as life expectancy, so more years are spent in poor health. Whilst Dr Finlay would have been focused on Scottish data, it is telling that, although a male in England could expect to live 79.4 years in 2018–20, his average healthy life expectancy was only 63.1 years – ie, he would have spent 16.3 of those years (20 per cent) in ‘not good’ health. In 2018–20 a female in England could expect to live 83.1 years, of which 19.3 years (23 per cent) would have been spent in ‘not good’ health.[3] And although females live an average of 3.7 years longer than males, most of that time (3 years) is spent in poor health. Dr Finlay is busy providing care to an expanded cohort of older patients with health challenges.
• The modern-day Dr Finlay will be providing many more preventative care interventions. These may include statin medications, anticoagulants, ACE inhibitors and betablockers. All of these have an evidence-based rationale for prevention but require monitoring with periodic blood tests, consultations and managing possible side effects or patient concerns about the latest newspaper headline.
• Whereas the original Dr Finlay would have seen a much higher proportion of his population smoking (82% of men and 41% of women in 1948)[4], modern Dr Finlay would see less smokers but much more significant obesity. Almost 75% of people aged 45–74 in the UK are living with overweight or obesity as well as over 20% of children before they leave primary school. There are also significant health inequalities in that those from lower income areas are significantly more likely to be living with obesity than those from more affluent areas.[5]
• Since the programme screened in the early 1960s, the number of GPs per 2000 head of populations has increased only slightly. Whilst the NHS has seen an increase in doctors from its inception in 1948 from 1.4 per 2,000 to 5.1 per 2,000, the GP numbers suggest that, since 1961 the number of GPs has only increased from one per 2000 to 1.6 per 2000 despite the increased workload.[6]
• In 2023, the current Dr Finlay is more likely to be a female, salaried GP working either within a portfolio career or working part time[7]. She may have strongly considered a career in hospital medicine before electing to pursue life as a GP.
• Her practice may well have GP vacancies[8], A Pulse survey in 2023 suggested that nearly one in five GP positions in the UK are unfilled according to a Pulse survey, the highest since the data has been collected.  Of the total number of GPs needed, 18.5% of positions were unfilled. Only one in 10 vacancies are currently being advertised, with GPs saying they had given up trying to recruit the remaining 8.5% of vacancies. Two thirds – 66% of practices – said they would hire at least one more GP if there were no problems in recruiting, while 32% said they would hire at least two more. [9]
• She faces increasing workload year on year[10]
• Whilst recognising that she needs a multi-disciplinary team and appropriate premises for modern general practice, she may have some challenges in securing resources for that[11]

The Finlay Manifesto

As a GP, I believe strongly that patients and the wider health systems needs an effective model of general practice. I think the evidence supports this. It cannot, however, be a “one size fits all” model as there are strong variations in practice populations and geographical locations.

The future of General Practice should be a priority. A resilient, effective general practice model will provide accessible, cost-effective care for patients with the potential to ameliorate the increases in demand upon hospital care.

Workforce is the single most important element of realising this approach and will require.

• System respect for clinicians working within primary care settings.
• Effective models of contracting for healthcare provision which secure high-quality services but which support those working within the service and the organisations responsible for delivering the services.
• Great training experiences which excite clinicians to pursue a career in primary care.
• New models of multidisciplinary care which provide safe, accessible, high quality of patient care whilst delivering sustainable services.
• Technology enabled clinicians and organisations using technical solutions that support effective care which is coordinated across practice teams and wider primary healthcare teams.
• A focus on developing continuity at a practice or organisation level which becomes part of patient’s “felt experience” of using services repeatedly. In most instances continuity as per the good Dr Finlay is not achievable.

We cannot have a single model for providing and commissioning services. When I first started practising, there was an initiative called Community Orientate Primary Care which advocated practices actively recognising local needs and developing services to respond to them. Health Visitors were seen as potential public health nurses who could drive some of the local need assessments and work as part of the primary healthcare team to develop appropriate service responses. Empowering primary care to develop services that meet local needs.

The Future Dr FinlAI

So how can technology support future models? My assertion is that this is through empowering clinicians rather than replacing or dictating care.

We must recognise the value of human interactions in securing holistic care that considers the physical, psychological, and social elements of a person’s condition and to effectively co-design care with our patients.

At present, primary care systems provide a range of alerts to clinicians, proposing potential interventions, providing alerts, identifying potential gaps in care, and suggesting opportunities to use more cost-effective medication. When in clinical practice, I find these computer interventions to be frequently ill timed within the workflow with the effect that I must cancel, check whether the alert is relevant and then restart, simmering with outrage. Alerting is also unsophisticated, raising a flag abut a drug whether it is relevant to that patient. In addition to poor calibration and timing, alerts are often frankly rude, documenting in the records that the awful Dr Lee had ignored the computer’s advice. All of this must improve as we move forward.

There is no doubt that Artificial Intelligence will have the ability to deliver more sophisticated assistance but must be developed and deployed to meet specific pain points. In a world, for example, where specialist services are increasingly demanding templated referrals rather than elegant “Dear Dr……… Kind Regards” approaches, systems could do a lot more to support GPs navigate the local system.

Decision support will also need to evolve to help GPs and other clinicians have the complex discussions required by patients with multimorbidity. I have previously blogged on this (multimorbidity). But effective technology support for these discussions and the ability to document the outcome of these discussions in a system wide care plan will, I believe, become essential.

Patient engagement in their care is also an important element of future general practice. How can we activate patients to become active in their care. Submitting their home readings directly into their records, adding to their care plans and reviewing their records? I am sure that this will substantially improve the safety of care and personalise the way in which care is delivered. There will, no doubt, be some technophobic objections but I am personally struck by the fact that nearly all telephone consultations are done to mobile numbers and digital confidence is clearly growing,

Healthcare data has the potential to move us towards better bespoke care for individual people, improved care for cohorts and better service planning at a system level. For people with complex needs, we can use interoperability and coordination to help provide a concierge service to navigate the healthcare system, potentially reducing admissions, improving care experiences, and improving outcomes.

I personally feel that the future of primary care will see significant technological developments which support better care. I feel that the future Dr FinlAI will still be a human who is technologically supported to provide and participated in excellent care but in turn will bring their very important interpersonal skills and “gut feelings” to brilliant care.

It may be that Dr Finlay of Levenford might thoroughly approve of the care delivered by Dr FinlAI.

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[1] https://www.nuffieldtrust.org.uk/sites/default/files/2018-11/improving-access-and-continuity-in-general-practice-summary-final.pdf

[2] https://www.statista.com/statistics/1040159/life-expectancy-united-kingdom-all-time/

[3] What Is Happening to Life Expectancy in England? | The King’s Fund 2022

[4] https://ash.org.uk/uploads/Smoking-Statistics-Fact-Sheet.pdf?v=1697728811

[5] https://www.rcplondon.ac.uk/news/world-obesity-day-let-s-talk-about-drugs

[6] https://www.nuffieldtrust.org.uk/resource/the-nhs-workforce-in-numbers#toc-header-6

[7] https://assets.publishing.service.gov.uk/media/5a7ff981ed915d74e33f7b37/CfWI_GP_in-depth_review.pdf

[8] https://assets.publishing.service.gov.uk/media/5a7ff981ed915d74e33f7b37/CfWI_GP_in-depth_review.pdf

[9] https://www.pulsetoday.co.uk/news/breaking-news/one-in-five-gp-positions-unfilled-as-vacancy-rates-reach-record-levels/

[10] https://www.rcgp.org.uk/getmedia/3613990d-2da8-458a-b812-ed2cf6d600a6/RCGP-Brief_GP-Shortages-in-England.pdf

[11] https://www.rcgp.org.uk/getmedia/3613990d-2da8-458a-b812-ed2cf6d600a6/RCGP-Brief_GP-Shortages-in-England.pdf