THE EUROPEAN DEFINITION OF GENERAL PRACTICE / FAMILY MEDICINE. WONCA EUROPE 2023 Edition

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THE EUROPEAN DEFINITION

GENERAL PRACTICE / FAMILY MEDICINE WONCA EUROPE 2023 Edition

THE EUROPEAN DEFINITION OF

GENERAL PRACTICE / FAMILY MEDICINE

WONCA EUROPE 2023 Edition

THE WONCA TREE – AS PRODUCED BY THE SWISS COLLEGE OF PRIMARY CARE

(Revised 2011 and 2023)

THE EUROPEAN DEFINITIONS of

The Key Features of the Discipline of General Practice

The Role of the General Practitioner

and

A description of the Core Competencies of the General Practitioner / Family Physician. Prepared for WONCA EUROPE (The European Society of General Practice/ Family Medicine), 2002.

Dr Justin Allen

Director of Postgraduate General Practice Education Centre for Postgraduate Medical Education, University of Leicester, United Kingdom

President of EURACT

Professor Bernard Gay

President, CNGE, Paris, France University of Bordeaux, France

Professor Harry Crebolder

Maastricht University The Netherlands

Professor Jan Heyrman

Catholic University of Leuven, Belgium

Professor Igor Svab

University of Ljubljana, Slovenia

Dr Paul Ram

Maastricht University The Netherlands

Edited by:

Dr Philip Evans

President WONCA Europe

This statement was published with the support and co-operation of the WHO Europe Ofce, Barcelona, Spain.

Revised in 2005 by a working party of EURACT Council led by Dr Justin Allen, on behalf of WONCA European Council.

Revised in 2011 by a Commission of the WONCA European Council led by Dr. Ernesto Mola and Dr. Tina Eriksson

Revised in 2023 by a Commission of the WONCA European Council led by Professor Adam Windak, Dr. Andrée Rochfort and Dr. Jean-Pierre Jacquet

Design and Layout: Gözde Usgurlu (gozde@uskur.com.tr)

Table of Contents

1. INTRODUCTION TO THE 2002 EDITION 4 INTRODUCTION TO 2023 REVISION 5 INTRODUCTION TO 2011 REVISION 6 INTRODUCTION TO 2005 REVISION 6

2. THE EUROPEAN DEFINITIONS 2023 7 THE DISCIPLINE AND SPECIALTY OF GENERAL PRACTICE / FAMILY MEDICINE 7

3. EXPLANATORY NOTES, RATIONALE AND ACADEMIC REVIEW - THE NEW DEFINITIONS 9 3.1 EXPLANATORY NOTES 9 3.2 RATIONALE FOR THE DEFINITIONS - ACADEMIC REVIEW AND ANALYSIS 12

4. EXPLANATORY NOTES, RATIONALE AND ACADEMIC REVIEW – THE CORE COMPETENCIES 22 4.1. EXPLANATORY NOTES 22 4.2 ESSENTIAL APPLICATION FEATURES 24 4.3 IMPLEMENTATION BEDROCK 25 4.4 RATIONALE FOR THE CORE COMPETENCIES; ACADEMIC REVIEW AND ANALYSIS 26

5. APPENDICES 30 Appendix 1 30 Appendix 2 31 Appendix 3 32 Appendix 4 33 Appendix 5 34

Using this document

This document contains statements of the characteristics of the discipline and the core com petences, and then sections with short explanatory notes. This is followed by a full explanation of the rationale, and the supporting academic analysis for each, which is important for those wishing to gain a greater understanding of the rationale for their development.

It provides essential information on the discipline of general practice, which should be used to inform those responsible for delivering health care, developing teaching and learning pro grammes for training, and for those learning our discipline.

A shortened version has also been published which contains only the explanatory notes.

1. INTRODUCTION TO THE 2002 EDITION

This consensus statement defnes both the discipline of general practice / family medicine, and the profes sional tasks of the family doctor; it also describes the core competencies required of general practitioners. It delineates the essential elements of the academic discipline and provides an authoritative view on what family doctors in Europe should be providing in the way of services to patients, in order that patient care is of the highest quality and also cost effective. From the defnitions within this paper the agendas for edu cation, research, quality assurance can be derived, to ensure that family medicine will develop to meet the health care needs of the population in the 21st century.

There are signifcant differences in the way that health care systems are organised and family medicine is practiced throughout Europe. For European Union countries, and those aspiring to join the Union, med

ical education is governed by EU Directive 93/16 which is primarily intended to promote free movement of doctors. Unfortunately within the Directive there is a lack of emphasis on the content and quality of post

graduate training. It is therefore self-evident and of great importance that, for the protection of patients, family doctors should receive training that will equip them with the necessary skills to practice in any mem

ber state.

This statement has been produced on behalf of WON CA Europe (The European Society of General Practice / Family Medicine) the Regional Organisation of the World organisation of Family Doctors (WONCA).

WONCA Europe provides the academic and scientif ic leadership and representation for the discipline of Family Medicine throughout the continent. Its mem bership comprises the national academic organisa tions of Family Medicine from 30 European countries, and direct membership from individual family doctors.

REFERENCE

Its main role is to promote and develop the discipline in order to achieve and maintain high standards of ed ucation, training, research and clinical practice for the beneft of individual patients and communities.

Reform of national health systems is a common feature in Europe as elsewhere in the world. Given the chang es in demography, medical advances, health econom ics, and patients’ needs and expectations new ways of providing and delivering health care are being sought. International evidence1 indicates that health systems based on effective primary care with highly -trained generalist physicians (Family Doctors) practising in the community, provide both more cost effective and more clinically effective care than those with a low pri

mary care orientation.

It is vital that the complex and essential role of Fam ily Doctors within health systems is fully understood within the medical profession, but also by the profes sions allied to medicine, health care planners, econ omists, politicians and the public. Within Europe in creased investment in Family Medicine is required to

enable health systems to fulfl their potential on behalf of patients, investment not just in relation to human resources and infrastructure but with regard to edu cation, research and quality assurance.

These new defnitions and the statement of core com petencies are published in order to inform and to con tribute to the debate on the essential role of family medicine within health systems, at both national and pan –European levels.

Dr Philip Evans, President WONCA Europe, 2002

1. Starfeld B. Primary care: balancing health needs, services and technology. Oxford: Oxford University press,1998

INTRODUCTION TO 2023 REVISION

Professor Adam Windak

Dr. Andrée Rochfort

Dr. Jean-Pierre Jacquet

This revision of the European Defnition of General Practice / Family Medicine is necessary in 2023 to highlight the relevance of One Health, Planetary Health and Sustainability to the discipline of GP/FM and to refect the urgency of action that is required by all who work in GP/FM and their leaders and representatives for the critical reason of preparing today for the future of humanity.

‘One Health’ is an integrated, unifying approach to balance and optimize the health of people, all animals and the environment¹

‘Planetary health’ is defined as the health of humans and the natural systems on which human health depends such as water, air and soil, which also impact on plant life, food and energy systems².

The Earth’s natural systems are the foundation of the Sustainable Development Goals³.

We all share the same resources, and we are co-dependent on environmental factors. In recent years we have been made aware of how we as humans contaminate water air and soil during our activities of everyday living, and also when at work in the healthcare sector delivering healthcare to patients, such as when prescribing, re questing medical tests and referring people to other services they must travel to. We are all actively consuming things, ranging from the raw materials themselves (energy, water, fuel) to processed products (e.g. food). We also do this in healthcare and other related activities. As a consequence, we should all be concerned with what resources are consumed to produce these activities, what pollution is generated and what waste is produced. We need to know how we can help our planet not to be damaged as it supplies resources for our modern living environments, and how we can avoid making our planet unhealthy as we humans escalate our consumption of resources. The potential of primary care to positively impact healthcare sustainability and address the impact of climate and natural environment change is substantial. As frontline healthcare workers within their respective communities, primary care providers can advocate for measures to reduce the effects of climate and environ ment change, encourage public participation, and promote activities that safeguard individuals from the conse

quences of these changes⁴.

REFERENCES

1. One Health. World Health Organization.

https://www.who.int/europe/initiatives/one-health

2. WONCA Statement on Planetary Health and Sustainable Development Goals. https://www.globalfamilydoctor.com/news/planetary healthandsustainabledevelopmentgoals.aspx

3. Sustainable Development Goals. United Nations, Department of Economic and Social Affairs https://sdgs.un.org/goals

4. Klemenc Ketiš Z, Rochfort A. Sustainability for Planetary Health: A Seventh Domain of Quality in Primary Care. Zdr Varst. 2022 Sep 28;61(4):198-200.

INTRODUCTION TO 2011 REVISION

Dr. Ernesto Mola

Dr. Tina Eriksson

At the meeting of 2010 in Malaga the WONCA Europe Council decided to appoint a small Commission, made up of people from different countries and networks, to make a minor revision of the European Defnition of General Practice in order to include two new concepts: Patient Empowerment and Continuous Quality Improvement.

Following a work plan agreed upon with the Executive Board, the commission examined two systematic propos als, based on a wide range of background knowledge, concerning the inclusion into the defnitions of patient empowerment and of continuous quality improvement.

At the end an amended version of the defnitions (based on the members opinions) was written down and sent to the Colleges in July 2011 to allow for an informed discussion at the subsequent European Council in Warsaw, where it was approved.

“Promotes patient empowerment” has been included as a 12th characteristic of the defnition I and a few sen tences have been added in defnitions II and III and in the explanatory notes.

Concerning Continuous quality improvement there isn’t a new bullet in the frst defnition, because it is not a core characteristic of general practice but of all the disciplines. Few sentences have been changed or added in defnitions II and III and in the explanatory notes.

The minor revision was aimed to update the defnitions and make them more adherent to the reality of general practice and of primary care and to the needs created by social and epidemiological changes.

INTRODUCTION TO 2005 REVISION

Professor Igor Svab, President WONCA Europe 2005

Since the defnition was frst accepted in 2002, it has received a wide attention by family physicians, academics and policymakers. It has been translated in most European languages and has been a basis for family practice curricula and a starting point for negotiating contracts with family physicians in many European countries. It has managed to be relevant to family physicians throughout Europe, regardless the enormous differences in the ways family medicine is practiced and taught.

Nevertheless, there was a feeling that more work should be done in order to improve its clarity, so that it would be more easily understandable. This is the reason why the defnition was revised and a new version created.

The 2005 revision of the document has maintained all the elements of the previous defnition. The defnition still defnes both the discipline of general practice / family medicine, and the professional tasks of the family doctor and describes the core competencies required of general practitioners. All the key features of the discipline and the core competencies have remained the same.

The revised defnition will certainly still be used in many occasions when family medicine is being discussed. It has already become a very useful instrument in negotiations with policymakers, educators, media and physi cians themselves.

WONCA Europe will continue to promote the defnition through its member colleges and the networks.

2. THE EUROPEAN DEFINITIONS 2023

THE DISCIPLINE AND SPECIALTY OF

GENERAL PRACTICE / FAMILY MEDICINE

General practice / family medicine is an academic and scientifc discipline, with its own educational content, research, evidence base and clinical activity, and a clinical specialty orientated to primary care.

I. The characteristics of the discipline of general practice/family medicine are that it:

a) is normally the point of frst medical contact within the health care system, providing open and unlimited access to its users, dealing with all health problems re gardless of the age, sex, or any other characteristic of the person concerned.

b) makes efcient use of health care resources through co-ordinating care, working with other professionals in the primary care setting, and by managing the inter face with other specialities taking an advocacy role for the patient when needed.

c) develops a person-centred approach, orientated to the individual, his/her family, and their community.

d) promotes patient empowerment

e) has a unique consultation process, which establish es a relationship over time, through effective commu nication between doctor and patient

f) is responsible for the provision of longitudinal con tinuity of care as determined by the needs of the pa tient.

g) has a specifc decision making process determined by the prevalence and incidence of illness in the com munity.

h) manages simultaneously both acute and chronic health problems of individual patients.

i) manages illness which presents in an undifferentiat ed way at an early stage in its development, which may require urgent intervention.

j) promotes health and wellbeing of patients and the ecosystems they live in both by appropriate and effec tive intervention.

k) has a specifc responsibility for the health of the community and environment.

l) deals with health problems in their physical, psycho logical, social, cultural, environmental and existential dimensions.

II. The Specialty of General Practice / Family Medicine

General practitioners/family doctors are specialist physicians trained in the principles of the discipline. They are personal doctors, primarily responsible for the provision of comprehensive and continuing care to every individual seeking medical care irrespective of age, sex and illness. They care for individuals in the context of their family, their community, their culture and integrated health of the planet, always respecting the autonomy of their patients.

They recognise they will also have a professional re sponsibility to their community and environment. In negotiating management plans with their patients they integrate physical, psychological, social, cultural, existential and planetary health-related factors, utilis ing the knowledge and trust engendered by repeated contacts. General practitioners/family physicians ex ercise their professional role by promoting health, pre venting disease and providing cure, care, or palliation and promoting patient empowerment and self-man agement in regard to the co-benefts of improving in dividual and planetary health. They do this by caring for the ecosystem made up of people, animals and the natural environment, being aware of their unique po sition as a role model for their patients regarding the promotion of leading a sustainable way of life. This is done either directly or through the services of others according to health needs and the resources available within the community they serve, assisting patients where necessary in accessing these services. They must take the responsibility for developing and main taining their skills, personal balance and values as a basis for effective and safe patient care. Like other medical professionals, they must take responsibility for continuously monitoring, maintaining and if neces sary improving clinical aspects, services and organisa tion, patient safety and patient satisfaction of the care they provide.

III. The Core Competencies of the General Practition er / Family Doctor

A defnition of the discipline of general practice/family medicine and of the specialist family doctor must lead directly the core competencies of the general practi tioner/family doctor. Core means essential to the dis cipline, irrespective of the health care system in which they are applied.

The twelve central characteristics that defne the dis cipline relate to twelve abilities that every specialist family doctor should master. They can be clustered into six core competencies (with reference to the characteristics):

1. Primary care management (a,b)

2. Person-centred care (c,d,e,f)

3. Specifc problem solving skills (g,h)

4. Comprehensive approach (i,j)

5. Community orientation (k)

6. Holistic modelling (l)

Particularly in reference to the competencies 1. and 3. quality improvement must be considered included as a fundamental ability.

As a person-centred scientifc discipline, three addi tional features should be considered as essential in the application of the core competences:

a. Contextual: Understanding the context of doctors themselves and the environment in which they work, including their working conditions, community, cul ture, fnancial and regulatory frameworks.

b. Attitudinal: based on the doctor’s professional capa bilities, values and ethics

c. Scientifc: adopting a critical and research based approach to practice and maintaining this through continuing learning and quality improvement

One Health, Planetary Health and Sustainability create the bedrock, allowing a new integrated approach to all of the six core competencies, twelve characteristics and three additional features essential in their application.

3. EXPLANATORY NOTES, RATIONALE AND ACADEMIC REVIEW - THE NEW DEFINITIONS

3.1 EXPLANATORY NOTES

The Discipline and Specialty of General Practice/Family Medicine

There is a need to defne both the discipline of general practice/family medicine and the role of the specialist family doctor. The former is required to defne the academic foundation and framework on which the discipline is built, and thus to inform the development of education, research, and quality improvement. The latter is need ed to translate this academic defnition into the reality of the specialist family doctor, working with patients in health care systems throughout Europe.

3.1.1 The characteristics of the discipline of general practice/family medicine are that it:

a) is normally the point of frst medical contact within the health care system, providing open and unlimited access to its users, dealing with all health problems regardless of the age, sex, or any other characteristic of the person concerned

“Normally” is used to indicate that in some circum stances, e.g. major trauma, it is not the frst point of contact. However it should be the point of frst con tact in most other situations. There should be no bar riers to access, and family doctors should deal with all types of patient, young or old, male or female, and their health problems. General practice is the essential and the frst resource. It covers a large feld of activities determined by the needs and wants of patients. This outlook gives rise to the many facets of the discipline and the opportunity of their use in the management of individual and community problems.

This coordinating role is a key feature of the cost ef fectiveness of good quality primary care ensuring that patients see the most appropriate health care profes sional for their particular problem. The synthesis of the different care providers, the appropriate distribu tion of information, and the arrangements for ordering treatments rely on the existence of a coordinating unit. General practice can fll this pivotal role if the struc tural conditions allow it. Developing team work around the patient with all health professionals will beneft the quality of care. By managing the interface with other

specialties the discipline ensures that those requiring high technology services based on secondary care can access them appropriately. A key role for the discipline is to provide advocacy, protecting patients from the harm which may ensue through unnecessary screen ing, testing, and treatment, and also guiding them through the complexities of the health care system.

The discipline recognizes the responsibility to mon itor and systematically assess the quality and safety, in a range of aspects of the care delivered by GPs and practices, followed by action aimed also at improving quality.

c) develops a person-centred approach, orientated to the individual, his/her family, and their community.

Family medicine deals with people and their problems in the context of their life circumstances, not with im personal pathology or “cases”. The starting point of the process is the patient. It is as important to understand how the patient copes with and views their illness as dealing with the disease process itself. The common denominator is the person with their beliefs, fears, ex

pectations and needs.

d) promotes patient empowerment

Family medicine is in a strategic position to promote the goals of patient empowerment and self manage ment. Longitudinal care, a multidisciplinary approach, a strong relationship based on a unique consultation process and on trust, a person-centred approach, are the starting points for a continuous educational pro

cess aimed to empower the patient.

e) has a unique consultation process, which establish es a relationship over time, through effective commu nication between doctor and patient

Each contact between patient and their family doctor contributes to an evolving story, and each individual consultation can draw on this prior shared experience. The value of this personal relationship is determined by the communication skills of the family doctor and is in itself therapeutic.

f) is responsible for the provision of longitudinal con tinuity of care as determined by the needs of the pa tient.

The approach of general practice must be constant from birth (and sometimes before) until death (and sometimes afterwards). It ensures the continuity of care by following patients through the whole of their life. The medical fle is the explicit proof of this con stancy. It is the objective memory of the consultations, but only part of the common doctor-patient history. Family doctors will provide care over substantial pe

riods of their patients’ lives, through many episodes of illness. They are also responsible for ensuring that healthcare is provided throughout the 24 hours, com missioning and coordinating such care when they are unable to provide it personally.

g) has a specifc decision making process determined by the prevalence and incidence of illness in the com munity.

Problems are presented to family doctors in the com munity in a very different way from the presentations in secondary care. The prevalence and incidence of illnesses is different from that which appears in a hospital setting and serious disease presents less fre quently in general practice than in hospital because there is no prior selection. This requires a specifc probability based decision-making process which is informed by a knowledge of patients and the commu nity. The predictive value, positive or negative of a clin ical sign or of a diagnostic test has a different weight in family medicine compared to the hospital setting. Frequently family doctors have to reassure those with anxieties about illness having frst determined that such illness is not present.

h) manages simultaneously both acute and chronic health problems of individual patients.

Family medicine must deal with all of the health care problems of the individual patient. It cannot lim it itself to the management of the presenting illness alone, and often the doctor will have to manage mul tiple problems. The patient often consults for sever al complaints, the number increasing with age. The simultaneous response to several demands renders necessary a hierarchical management of the problems which takes account of both the patient’s and the doc tor’s priorities.

i) manages illness which presents in an undifferenti ated way at an early stage in its development, which may require urgent intervention.

The patient often comes at the onset of symptoms, and it is difcult to make a diagnosis at this early stage. This manner of presentation means that important decisions for patients have to be taken on the basis of limited information and the predictive value of clin ical examination and tests is less certain. Even if the signs of a particular disease are generally well known, this does not apply for the early signs, which are often non-specifc and common to a lot of diseases. Risk management under these circumstances is a key fea ture of the discipline. Having excluded an immediate

ly serious outcome, the decision may well be to await further developments and review later. The result of a single consultation often stays on the level of one or several symptoms, sometimes an idea of a disease, rarely a full diagnosis.

j) promotes health and well being of patients and the ecosystems they live in both by appropriate and effec tive intervention.

Interventions must be appropriate, effective and based on sound evidence whenever possible. Intervention when none is required may cause harm, and wastes valuable health care resources. Interventions should take into account the well-being not only of individu als, but also of living (fora and fauna) and non-living (climate, air, water, soil/earth, food, etc.) components of the surrounding ecosystems.

k) has a specifc responsibility for the health of the community and environment.

The discipline recognises that it has a responsibility both to the individual patient and to the wider com munity in dealing with health care issues. This ap proach includes integrated health of people, animals and environment, known as the One Health concept. On occasions this will produce a tension and can lead to conficts of interest, which must be appropriately managed.

l)deals with health problems in their physical, psycho logical, social, cultural, environmental and existential dimensions.

The discipline has to recognise all these dimensions si multaneously, and to give appropriate weight to each. Illness behaviour and patterns of disease are varied by many of these issues and much unhappiness is caused by interventions which do not address the root cause of the problem for the patient.

3.1.2 The Specialty of General Practice/ Family Med icine

individual seeking medical care irrespective of age, sex and illness. They care for individuals in the context of their family, their community, their culture and envi ronment they live in, always respecting the autonomy of their patients. They recognise they will also have a professional responsibility to their community. In ne gotiating management plans with their patients they integrate physical, psychological, social, cultural and existential factors, utilising the knowledge and trust en gendered by repeated contacts. General practitioners/ family physicians exercise their professional role by pro

moting health, preventing disease, providing cure, care, or palliation and promoting patient empowerment and self-management. They do this caring for One Health, Planetary Health and Sustainable Development Goals. This is done either directly or through the services of others according to their health needs and resources available within the community they serve, assisting patients where necessary in accessing these services. They must take the responsibility for developing and maintaining their skills, personal balance and values as a basis for effective and safe patient care.

This defnition of the role of the family doctor puts the characteristics of the discipline described above into the context of the practising physician. It represents an ideal to which all family doctors can aspire. Some of the elements in this defnition are not unique to family doctors but are generally applicable to the profession as a whole. The speciality of general practice/family medicine is nevertheless the only one which can im plement all of these features. An example of a com mon responsibility is that of maintaining skills, which may be a particular difculty for family doctors who often work in isolation.

3.2 RATIONALE FOR THE DEFINITIONS - ACADEMIC REVIEW AND ANALYSISIntroduction

The Leeuwenhorst group produced its statement “The General Practitioner in Europe” in 1974¹. At that stage general practice/family medicine was in its infancy as a discipline, particularly with regard to its teaching and research base. Almost 30 years later the world has moved on and nowhere has this change been more apparent than in the provision of health care. Gener al practice / family medicine is now well established in all health care systems in Europe and is recognised by health service providers as being of ever increas ing importance. This has been emphasised by WHO Europe in its 1998² framework document, and by the way that in most countries in the former Soviet block general practice/family medicine is being introduced as the basis for their new health care systems.

Society has changed over the last 30 years and there has been an increasing role for the patient as a deter mining factor in health care and its provision. The opin ion of the clinician is no longer regarded as sacrosanct and a new dialogue is emerging between health care consumers and providers. The future family doctor has to be not only aware of this change but to be able to thrive in such an environment. It is important that the discipline of general practice / family medicine con tinues to evolve as the health care systems in which it operates change, and that it responds to the health needs of patients. Family doctors must be involved in the continuing development of their health care sys tem, and as individuals must be able to change in order to meet these new challenges.

Van Weel, in his recent lecture to the RCGP Spring Meeting³, emphasised the need for academic develop ment to enable transfer of knowledge, expertise and experience, to develop techniques and methodology addressing the specifc requirements of general prac tice, and to explore the effectiveness of general prac tice care. He also emphasised the importance of the value basis of family medicine itself and the need for a common culture of teaching, research and training. It is timely therefore to re-examine the defnitions of the role of the family doctor, and to develop a clear state ment of the characteristics of the discipline of general practice/family medicine.

There is a further imperative for European Union coun tries, and those aspiring to join the Union. EU Direc tive 93/16⁴ is intended to promote free movement of doctors, and therefore, for the protection of patients, it is self-evident that family doctors should receive training that will equip them with the necessary skills to practice in any member state, as their qualifcation entitles them to practice anywhere in the EU without further training. It follows that it is important to have a consensus view defning the characteristics of the discipline and the tasks that family doctors should do.

Directive 93/16 only defnes a training period of mini mum of 2 years and a minimum of six months in a gen eral practice setting; this has been lengthened to 3 or more years by some countries. The UEMO Consensus document of 1994 on specifc training for general prac tice⁵ argued the need to prolong the period of training to a minimum duration of 3 years including a practical and theoretical part, of which a minimum of 50% of clinical training time must be spent in a general prac tice environment. The Advisory Committee on Medical Training (ACMT)⁶ accepted the views of UEMO and ad vised the European Commission to revise the Directive accordingly - to establish a training period of 3 years, 50% to be located in practice, and general practition ers to be involved and responsible for general practice training at all levels. However unfortunately this advice has not yet been accepted by the European Commis sion.

Problems with bringing about change to Title 4 of the medical directive, which relates to general practice/ family medicine and the need to develop the place of family medicine within the curriculum of medical uni versities have led to the suggestion that further de velopments in the discipline could be better achieved if “specialist in family medicine” became one of the medical specialties listed in Title 3 - which covers all of other medical specialties. It is not part of this paper to explore this issue; the purpose here is to elaborate the principles that underpin the discipline of general practice/family medicine.

ROLE, DISCIPLINE AND HEALTH CARE SYSTEM

There are different ways of approaching the problem of producing a new defnition. The method used by the Leeuwenhorst group, and more recently by Olesen et al⁷, was to defne the parameters of the discipline by describing the types of tasks that a family doctor has to carry out. An alternative approach is to try to defne the fundamental principles of the discipline of general practice/family medicine. This approach has been tak en by Gay in a presentation to the inaugural meeting of WONCA Europe in Strasbourg in 1995⁸ and was also

used in the framework document developed by WHO Europe.

Gay has suggested that there is a relationship between principles and tasks with some infuences on the task required from both the patients and the health care system. This should then lead to defnitions of com

petence which will determine the content of general practice education. This is represented in fgure 1.

Figure 1 - Relationship between the principles of the discipline of general practice and the tasks demanded of family doctors

This diagram indicates the dynamic relationship be tween the underlying principles of the discipline and the tasks that family doctors have to perform. These tasks are determined to a considerable extent by the health care system in which GPs work and the chang ing needs and demands of the patients.

The characteristics as described by WHO Europe, can also be considered as the aims for general practice within the health care system. These concepts bring into play ideas of effectiveness and if one accepts that the health care system determines to a greater or less

er extent the task that a family doctor is able to under take, any new defnition must take into account the context in which the family doctor works and refect the changing needs of patients and advances in health care delivery.

These approaches are not mutually exclusive and any new defnitions will have to take into account the un derpinning principles of the discipline, the core tasks of the family doctor within the health care system and the infuence of the health care system on the provi sion of family medicine.

The principles of the discipline as suggested by Gay were: -

1. Patient centred approach

2. Orientation on family and community context

3. Field of activities determined by patient needs and requests

4. Unselected and complex health problems 5. Low incidence of serious diseases

6. Diseases at early stage

7. Simultaneous management of multiple complaints and pathologies

8. Continuing management

9. Coordinated care

10. Efciency

and are in many ways similar to the characteristics of general practice/family medicine described in the WHO framework statement: -

A. General

B. Continuous

C. Comprehensive

D. Co-ordinated

E. Collaborative

F. Family orientated

G. Community orientated

The WHO statement goes on to elaborate what it means by these 7 characteristics.

General: -

• Unselected health problems of the whole population

• Does not exclude categories because of age, sex, class, race or religion, nor any category of health problem

• Easy access, unlimited by geographical, cultural, administrative or fnancial barriers

Continuous: -

• Person centred

• Longitudinal health care, over substantial periods of life, not limited to one illness episode

Comprehensive:-

integrated care involving

• Health promotion, disease prevention, curative, rehabilitative and supportive care • Physical, psychological and social perspectives

• Clinical, humanistic and ethical aspects of the doctor – patient relationship

Co-ordinated: -

• Care managed at frst contact

• Referral to specialist services

• Providing information to patients on available services

• Co-ordinate and manage care

Collaborative: -

• Working in multidisciplinary teams

• Delegating care where appropriate

• Exercising leadership

Family oriented care:-

addressing individual problems in the context of

• Family circumstances

• Social and cultural networks

• Work and home circumstances

Community orientated: -

suggests that family doctors should consider individual problems in the context of: - • The health needs of the community

• Other professionals and agencies

WONCA in its 1991 statement on the Role of the General Practitioner/Family Physician in Health Care Systems⁹, produced a defnition of the general practitioner role and linked it to features of general practice/family medi cine which it describes under the categories of commitments and specifcations

The WONCA 1991 statement includes the following

▶ Comprehensive care

▶ Orientation to the patient

▶ Family focus

▶ Doctor/patient relationship

▶ Co-ordination with other services

▶ Advocacy

▶ Accessibility and resource management.

There is a great overlap in the WHO characteristics, the “specifcations” in the WONCA document and in the prin ciples as defned by Gay. This can be demonstrated by cross- mapping them as in the following table:

WHO 1998	WONCA 1991	“Principles” as described by Gay
General	Comprehensive care	3. Field of activities determined by patient needs and requests 4. Unselected and complex health prob lems
Continuous*	Orientation to the patient	1. Patient centred approach 8. Continuing management
Comprehensive	Comprehensive care	3. Field of activities determined by patient needs and requests 4. Unselected and complex health problems
Co-ordinated	Co-ordination with other services	9. Coordinated care
Collaborative	Co-ordination with other services	9. Coordinated care
Family oriented	Family focus	2. Orientation on family and community con text
Community oriented	Commitment to the Community	2. Orientation on family and community con text

* Confusion in the use of language in the WHO document may cause some difcul

ty. The confusion is between the words “continuous”, and “continuing” and in the

context of the WHO document “continuing” would be more appropriate.

Continuous - means without a break; uninterrupted; such as the perimeter fence

around a prison.

However there are some interesting differences. The items described by WHO and WONCA are dealing with professional activity in the health care system and not the discipline as a medical activity with a specifc pro

cess. Indeed, the 3 following items concern the disci pline and are not really integrated in the WHO or WON CA characteristics.

“Low prevalence of serious diseases”, “diseases at ear ly stage”, and “simultaneous management of multiple complaints and pathologies” in Gay’s presentation are part of the “comprehensive care” in the WONCA paper, but are not covered in the characteristics of WHO. They cover a crucial aspect of general practice – that it is a people based discipline (as opposed to pathology or organ based), and that it is normality orientated (as opposed to the abnormality orientation of secondary care), but that family doctors will also meet and need to manage serious illness at an early and undifferen tiated stage. The statement from WONCA also makes the point that the incidence of illness, and the signs at presentation are very different in primary care from those seen in hospital, where these are usually taught.

The WHO Framework fails to explore in any depth that which must be regarded as the cornerstone of general practice/family medicine, the individual consultation between patient and family doctor. Gay proposed a theoretical model of general practice: a GLOBAL MOD EL, open minded, considering the disease as the result of organic, human and environmental factors. This concept, in which health is a complex framework, is like the bio psychosocial model of Engel: it’s a “holistic” model.

The consultation is included in the WONCA statement, which also describes the need to express problem defnition for patients in both biomedical and human istic terms; that is in physical, psychological and so cial terms. This has its origin in the report of a work ing party of the Royal College of General Practitioners (RCGP)10, and has become so embedded in the thinking of the discipline that it is in danger of being taken for granted.

EEfciency is a further statement by Gay which is not specifcally mentioned in the WHO characteristics. This presumably refers to the cost efciency which is accepted as a characteristic feature of well developed family health care systems. The WONCA statement develops this idea further, suggesting that the family doctor has a role in resource management in health care systems.

The close inter-relationship between the defning principles of the discipline as previously described and the various role descriptions can be seen if one ex amines the latter in some detail. (See appendix 1.) The original Leeuwenhorst defnition appears to have the advantage over the others of having stood the test of

time and being widely accepted. It was very much set in its own time when general practice was a very new discipline with a limited research and education basis and was usually regarded as the branch of the medical profession to which one sank if one was unskilled in all others. It was informed, at least in part, by the job def nition produced by a working party of the Royal College of General Practitioners in 197210, which also seems to have informed the WONCA defnition. It covers many of the characteristics later described in the WHO frame work but put them into the context of day-to-day work in general practice. However it is not sufcient in itself to be the only defnition; it is not comprehensive – for example curative, rehabilitative and supportive care are not specifcally mentioned.

Olesen et al have stated that the original Leeuwen horst defnition is out of date and does not refect the reality of family medicine today. However it would ap pear that much of the detail of the dissatisfaction ex pressed by Olesen et al is because many of those who regard themselves as family doctors are working in healthcare systems in which it is not possible to com ply with all of the characteristics. Thus they drop some of the features that many would regard as key to the work of the family doctor, particularly losing the con cept of the community setting of the discipline and of longitudinal care - continuity. They cite examples such as family doctors working in emergency departments as support for their viewpoint.

The two succeeding defnitions, those of WONCA 1991 and Olesen 2000, still seem to have their roots very much in the Leeuwenhorst defnition. The WONCA 1991 statement appears to have made it much more relevant to different health care systems and incor porates, as has been described, some descriptors of the discipline. In its clinical decision making section it describes the early presentation of undifferentiated clinical problems, the large number of problems which do not ft with standard biomedical diagnoses and the different prevalence of illness and disease within the general practice setting as compared with the sec ondary care setting.

When considering health care systems the model of health care shown in fgure 2 is now generally accept ed11. If we use the defnition of primary care that is used in the introduction – “the setting within a health care system, usually in the patient’s own community in which the frst contact with the health profession

al occurs” – we are brought into a consideration of the context in which the family doctor works. The interfac es between self-care, primary,

secondary and tertiary health

care and the interactions be

tween the various health care

providers in each are important

issues to be considered.

Figure 2

There are a number of patterns of primary health care delivery in Europe, with differences in the patient pop ulation dealt with by family doctors, and an increasing number of different health professionals working in primary care in the different health care systems. The contexts in which such family doctors work are very different, but the underlying principles of the discipline should still apply. Obviously some health care systems may not be the most conducive to good family medi cine, and, though such systems are not easily amena

ble to change, we should not be afraid to put forward a view of the ideal model of the health care system which is likely to provide the best health outcomes and cost-efcient care . That is one which is based on high quality Family Medicine. This was one of the main thrusts of the WHO Framework document

The task is to defne that which is the unique activity of the family doctor – the clinical generalist. Family doc tors should through their activities in preventive med icine and health education have an infuence on self care. In some health care systems they infuence the provision of both secondary and tertiary care and may have a facilitating role in co-ordinating appropriate ac cess to these services. In others, narrow specialists also work in a primary care setting, often dealing with problems that in other countries would be managed by family doctors. In some health care systems family doctors, working predominantly in primary care, may have a limited secondary care role.

DISCUSSION

Can all these varied statements and defnitions be Can all these varied statements and defnitions be com bined into one defnition? Do we need a new defnition, and should it be a description of the task/role or of the features of the discipline? This was put to the test in a workshop at the 2001 WONCA Europe Conference in Tampere, Finland, where a substantial majority felt there should be a new defnition, and that it should en

compass a description of both task and the principles of the discipline.

There are many similarities between the statements of the principles which defne our discipline, and in the task descriptions of a general practitioner, but there also signifcant differences. As has been pointed out there are gaps in all the statements, which may be due to differences in the way in which the statements are interpreted. None of these defnitions per se encom pass all the key features of the discipline of general practice. There is therefore a need for a synthesis of the various statements considered thus far to examine the differences, fll the gaps and ensure completeness

Much of the concern regarding the Leeuwenhorst def nition Olesen et al expressed in their paper appears to be in its interpretation in absolute terms. For example what is meant by personal care? Is it care by the same doctor on every occasion? If not what are the condi tions when it is acceptable for a deputy – e.g. out of working hours. Or do we mean care for people rather than pathology – the person orientation of care de scribed by Gay and the WHO? Again the Tampere work shop was consulted on this; very few participants felt that GPs should be providing 24-hour personal care, but a substantial majority felt that they should provide continuing personal care over a substantial period of time.

When we come to consider our defnitions there are a number of other issues that must be emphasised. The unique interaction between family doctor and pa tient that is the general practice consultation merits further exploration. This has been described as a cov enant by McWhinney12, which has its own therapeutic effect. This relationship between doctor and patient in general practice caused Balint13 to coin the term “the drug doctor”. Using the consultation interaction as a therapeutic tool must be regarded as a key feature of general practice and must be part of its training. Perei

ra-Gray14 has further explored the issue of continuity and the use of time by considering the separate con sultations between the GP and the patient over time as part of a continuum. He noted that the average citizen in the United Kingdom consults their GP fve times per year making a cumulative time of 47 minutes per an

num.

An area of increasing importance over recent years has been the concept of patient autonomy and with it the role of the family doctor in developing the expertise of patients in managing their own illness, and contribut

ing to this management by changing behaviour. Em powering patients is a relevant task of general practice by promoting a continuous educational process aimed to increase their self-awareness necessary to effec tively assume responsibility for their health-related decisions15. A patient-empowerment approach re quires that patients’ perspectives regarding their con ditions, their goals, expectations, and needs are the focus of the treatment goals and management activ ities16. This is likely to become increasingly important as patients become better informed due to the wide variety of information systems now becoming available to them, for example the Internet.

Advocacy is featured only in the WONCA statement, al though it was in preliminary drafts of the WHO frame work. It is described as “helping the patient take an active part in the clinical decision-making process and working with the government and other authori ties to maximise equitable distribution of services to all members of society”. There would appear to be a further function of the family doctor, which is about assisting patients negotiate their way around the sec ondary and tertiary parts of their health care systems.

The epidemiology of general practice is essentially different from that of secondary care. Major illness presents early and in an undifferentiated way; many minor, self limiting problems are only or predominant

ly seen in primary care; and family medicine manages much of the longitudinal care of chronic illness. Many consultations are to relieve the anxiety of the possibil ity of illness in patients who have no pathology – the normality orientation of primary care. The concept of normality orientation is complex and covers a number of issues. It encompasses the activity of promoting health and well-being, and the expectation that many of the problems presented to them have no basis in pa thology. At the same time general practitioners must diagnose and manage serious illness, the incidence of which is different compared to secondary and tertiary care. They must use problem-solving skills to resolve the dilemma that this presents. A very complex task, which requires a specifc decision making process, based on the low incidence of serious disease, and the fact that the positive predictive value of symptoms and signs, and of diagnostic tests is different in primary

care, and, for a number of important conditions, lower than in the hospital setting. There is often no biomed ical cause for the distress that is presented by the pa tient, and it is important to know when to stop investi gating whilst continuing to care. There is also a need to protect patients from the damage of over-medicalisa tion of their problems, if necessary by “rescuing” them from unnecessary screening, tests, and treatment.

McWhinney17 emphasised the organ based model of biological processes, in which the way a particular organism behaves will in part depend on its history, context and environment. This requires general prac

titioners to seek complexity and to accept uncertainty and he makes the point that, of all clinical disciplines, general practice operates at the highest level of com plexity, and consequent uncertainty. In this lecture he emphasised several of the issues already discussed – relationships, individual person orientation, and the dualism between mind and body (physical, psycholog

ical and social).

In these days of consumerism and performance man agement there is an expectation that family doctors maintain their skills through lifelong learning, and take responsibility for monitoring, assessing and improving quality and safety of care18. In some health care sys tems this is leading to compulsory reaccreditation on a periodic basis and also compulsory quality manage ment systems¹⁹ and patient safety measures20. Other societal changes will alter the consumer view of the way healthcare is provided, and the general practition er must be fexible in order to respond to these chang es. This fexibility has to cope with the rapid changes in the bio-medical feld, which for the clinical generalist occurs over the whole spectrum of disease manage ment.

Increased travel and immigration can cause rapid changes in the distribution of health and disease. This presents new challenges for the general practitioner and a change in the epidemiology of general practice. The family doctor needs a broader understanding of cultural, ethnic and religious differences and their im pact on illness and health, and their implications for treatment.

The global crisis related to the COVID-19 pandemic has clearly shown the interdependence of human health and the well-being of the entire natural environment, consisting of fauna, fora and inanimate matter. This approach, defned in the Rockefeller-Lancet Commis sion report as Planetary Health21, and in the World Bank

report as One Health22, poses new challenges to fam ily medicine. They correspond closely with the 17 Sus tainable Development Goals set up by United Nations23 and endorsed by WONCA24. GPs need to understand

the far-reaching and multidimensional effects of their routine decisions (such as prescribing antibiotics or aerosol medications) on global issues such as climate change or the spread of infectious diseases. As natural leaders and authorities on health issues in their local communities, they also have a special responsibility to disseminate this knowledge among their patients.

There is also a developing role in relation to resource management. With the ever-increasing costs of health care the clinical generalist, in partner with his/her pa tient is in a unique position to determine priorities in health care provision and resource allocation. Family doctors also need to be aware of their role in promoting cost effective practice, not only in themselves but also in their colleagues. There may be a confict between the wants and needs of the individual patient, and the needs of the community as a whole; the family doctor needs to be aware of this, be able to strike an appropri ate balance, and communicate this to the patient.

An area which is not specifcally addressed in any of the previous defnitions is the concept of high-use skills and high-risk skills. High-use skills are those which are used frequently in a general practice setting because of the frequency that they are required, for example the examination of children, history taking under time limited conditions, examination of the ear nose and throat etc. High-risk skills are required in situations which present infrequently to the general practitioner where there is a major risk for the patient for example dealing with cardiopulmonary resuscitation, a patient with convulsions or an aggressive/dangerous patient.

Finally it must be clear that our education process must prepare family doctors for the very different clin ical processes which are not primarily mechanistic or technical in nature which is the way that medicine is still predominantly taught in medical schools through out the world.

There is a need for an authoritative statement which defnes both the discipline of general practice/family medicine and the tasks of the general practitioner, and relate them, at least in general terms, to the context of the health care system.

It should defne:

1. Those essential elements of the discipline which defne it and are not dependant on health care sys tems.

2. Those professional tasks which are generally ap plicable but can be varied by context. An example

of this might be that referral to secondary care is an essential component but that the gate keeping function to secondary care was not.

3. The professional tasks which, as a result of con textual differences, are not generally applicable but where that situation is regarded as unsatisfac tory (e.g. if we believe that family doctors should deal with all ages including children and this is not possible in a particular health care system) we should suggest that that health care system

REFERENCES

1. The General Practitioner In Europe: A statement by the work ing party appointed by the European Conference on the Teach ing of General Practice, Leeuwenhorst, Netherlands 1974

2. Framework for Professional and Administrative Development of General Practice / Family Medicine in Europe, WHO Europe, Copenhagen, 1998

3. Van Weel C. The Impact of Science on the Future of Medicine: RCGP Spring Meeting, 2001

4. Council Directive 93/16/EEC to facilitate the free movement of doctors and the mutual recognition of their diplomas, cer tifcates and other evidence of formal qualifcations; Ofcial Journal of the European Community, 165: 7/7/93

5. Proceedings UEMO Consensus Conference on Specifc Train ing for General Practice. UEMO. Published by The Danish Med ical Association. Copenhagen 1995

6. Report and Recommendations on the Review of Specifc Train ing in General Medical Practice: Advisory Committee on Medi cal Training (to the European Commission), XV/E/8433/95-EN October 1995

7. Olesen F, Dickinson J, Hjortdahl P. General Practice-time for a new defnition BMJ 2000; 320,354-357

8. Gay Bernard, What are the basic principles to defne general practice, Presentation to Inaugural Meeting of European Soci ety of General Practice/Family Medicine, Strasbourg, 1995

9. The Role of the General Practitioner / Family Physician in Health Care Systems: a statement from WONCA, 1991

10. The Future General Practitioner – Learning and Teaching: London; RCGP, 1972

11. The Nature of General Medical Practice – Report from General Practice 27: London; RCGP 1996

12. McWhinney Ian R, Primary care core values: core values in a changing world, BMJ, 1998, 317 (7147), 1807-1809

13. Balint M. The Doctor, his Patient and the Illness: Pitman Med ical; London, 1964

should change, in order to maximise the benefts to patients regarding health outcomes and to soci ety in relation to cost – effective care.

4. This leads us towards the new defnitions. We re quire a defnition of the characteristics or prin ciples of the discipline of family medicine AND a defnition of the role of family doctors, categorised by reference to the health care system in which they work.

14. Pereira-Gray D, Forty-seven minutes a year for the patient, British Journal of General Practice 1998; 48 (437): 1816-1817

15. Feste C, Anderson RM. Empowerment: from philosophy to practice. Patient Educ Couns 1995;/26:/139-4

16. Mola E., De Bonis J., Giancane R., Integrating patient empow erment as an essential characteristic of the discipline of gen eral practice/family medicine, EJGP, Sept 2008; 89-94

17. McWhinney Ian R The importance of being different. British Journal of General Practice, 1996, 46, 433-436

18. Schouten LM, Hulscher ME, van Everdingen JJ, Huisman R, Grol RP. Evidence for the impact of quality improvement col laboratives: systematic review. BMJ 2008; 336(7659):1491- 1494.

19. Dixon A, Khachatryan A. A review of the public health impact of the Quality and Outcomes Framework. Qual Prim Care 2010; 18(2):133-138.

20. Palacios-Derfingher L, O’Beirne M, Sterling P, Zwicker K, Har ding BK, Casebeer A. Dimensions of patient safety culture in family practice. Healthc Q 2010; 13 Spec No:121-127.

21. Whitmee S, Haines A, Beyrer C et al. Safeguarding human health in the Anthropocene epoch: report of The Rocke feller Foundation-Lancet Commission on planetary health. Lancet 2015;386(10007): 1973-2028. doi: 10.1016/S0140- 6736(15)60901-1.

22. Operational Framework for Strengthening Human, Animal, and Environmental Public Health Systems at their Interface. World Bank Report Number: 122980-GLB Available online at: http:// documents.worldbank.org/curated/en/703711517234402168/ Operational-framework-forstrengthening-human-ani mal-and-environmental-public-health-systems-at-their-in terface

23. Sustainable Development Goals. United Nations, Department of Economic and Social Affairs. Available online at: https:// sdgs.un.org/goals

24. WONCA Statement on Planetary Health and Sustainable De velopment Goals. Available online at: https://www.globalfami lydoctor.com/news/planetaryhealthandsustainabledevelop mentgoals.aspx

4. EXPLANATORY NOTES, RATIONALE AND ACADEMIC REVIEW – THE CORE COMPETENCIES

4.1. EXPLANATORY NOTES

The defnition of the discipline of general practice/family medicine and of the specialist family doctor must lead directly the core competencies of the general practitioner/family doctor.

Core means essential to the discipline, irrespective of the health care system in which they are applied.

The twelve characteristics of the discipline relate to twelve abilities that every specialist family doctor should master. Because of their interrelationship, they are clustered into six independent categories of core compe tence.

4.1.1. Primary Care Management

Includes the ability:

• to manage primary contact with patients, dealing with unselected problems;

• to cover the full range of health conditions;

• to co-ordinate care with other professionals in pri mary care and with other specialists;

• to master effective and appropriate care provision and health service utilisation;

• to monitor, assess and improve quality and safety of care;

• to make available to the patient the appropriate services within the health care system;

• to act as advocate for the patient

4.1.2. Person-centred Care

Includes the ability:

• to adopt a person-centred approach in dealing with patients and problems in the context of pa tient’s circumstances;

• to develop and apply the general practice consul tation to bring about an effective doctor-patient relationship, with respect for the patient’s auton omy;

• to communicate, set priorities and act in partner ship;

• to promote patient empowerment for self manage ment and prevention including behaviour change for healthy lifestyles

• to provide longitudinal continuity of care as de termined by the needs of the patient referring to continuing and co-ordinated care management to minimise duplication and waste of healthcare re sources

4.1.3. Specifc Problem Solving Skills

Includes the ability:

• to relate specifc decision making processes to the prevalence and incidence of illness in the commu nity;

• to selectively gather and interpret information from history-taking, physical examination, and in vestigations and apply it to an appropriate man agement plan in collaboration with the patient;

• to adopt appropriate working principles. e.g. in cremental investigation, using time as a tool and to tolerate uncertainty;

• to intervene urgently when necessary;

• to manage conditions which may present early and in an undifferentiated way;

• to make effective and efcient use of diagnostic and therapeutic interventions.

4.1.4. Comprehensive Approach

Includes the ability:

• to manage simultaneously multiple complaints and pathologies, both acute and chronic health problems in the individual;

• to promote health and well being by applying health promotion and disease prevention strategies ap propriately;

• to manage and co-ordinate health promotion, pre vention, cure, care and palliation and rehabilita tion;

• to work in a partnership with patients, other pro fessionals, public health and policy makers, to en hance the human response to the challenges of planetary health, one health and sustainability

4.1.5. Community Orientation

Includes the ability:

• to reconcile the health needs of individual patients and the health needs of the community in which they live in balance with available resources;

• to merge the health needs of patients and the community in which they live with the needs of planetary health..

• to choose an eco-responsible location of the prac tice with low consumption or even energy neutral facilities

• to choose the least polluting mode of professional medical practice.

4.1.6. Holistic Approach

Includes the ability:

• to use a bio-psycho-social model taking into ac count cultural, existential, and environmental di mensions

• to participate in informing the community about the co-benefts of patient and planetary health with particular reference to consumption of healthcare resources,

• to make rational choices when prescribing and deprescribing drugs, or choosing diagnostic tests, screening and preventive activities

4.2 ESSENTIAL APPLICATION FEATURES

In applying the competencies to the teaching, learning and practice of family medicine it is necessary to consid er three essential additional features; contextual, attitudinal and scientifc. They are concerned with features of doctors, and determine their ability to apply the core competencies in real life in the work setting. In general practice these may have a greater impact because of the close relationship between the family doctor and the people with whom they work, but they relate to all doctors and are not specifc to general practice.

4.2.1 Contextual Aspects

(Understanding the context of doctors themselves and the environment in which they work, including their working conditions, community, culture, fnancial and regulatory frameworks)

• Having an understanding of the impact of the lo cal community, including socio- economic factors, geography and culture, on the workplace and pa tient care.

• Being aware of the impact of overall workload on the care given to the individual patient, and the facilities (eg staff, equipment) available to deliver that care.

• Having an understanding of the fnancial and legal frameworks in which health care is given at prac tice level

• Having an understanding of the impact of the doc tor’s personal housing and working environment on the care that s/he provides

4.2.2 Attitudinal Aspects

(Based on the doctor’s professional capabilities, values, feelings and ethics)

• Being aware of one’s own capabilities and values - identifying ethical aspects of clinical practice (pre vention/diagnostics/ therapy/factors infuencing lifestyles);

• Having an awareness of self: an understanding that one’s own attitudes, and feelings are impor tant determinants of how one practises

• Justifying and clarifying personal ethics;

• Being aware of the mutual interaction of work and private life and striving for a good balance between them.

4.2.3 Scientifc Aspects

(Adopting a critical and research based approach to practice and maintaining this through continuing learn ing and quality improvement)

• Being familiar with the general principles, meth ods, concepts of scientifc research, and the fun damentals of statistics (incidence, prevalence, predicted value etc.);

• Having a thorough knowledge of the scientifc backgrounds of pathology, symptoms and diagno sis, therapy and prognosis, epidemiology, decision theory, theories of the forming of hypotheses and problem-solving, preventive health care;

• Being able to access, read and assess medical lit erature critically;

• Developing and maintaining continuing learning and quality improvement.

4.3 IMPLEMENTATION BEDROCK

The six core competencies and twelve characteristics of GP/FM already encompass the concepts of One Health, Planetary Health, and Sustainability, as they are illustrated as anchored in the bedrock beneath the science, at titude and context of the defnition.

However, it is necessary to describe in detail how the core competencies and characteristics will work for envi ronmental health, by focussing on improving elements of quality of care that are relevant for different commu nities and contexts. The implementation bedrock shows that general practitioners/ family physicians need to develop the new approaches required of our discipline in unison with patients, to integrate us with other players in the health sector, policy makers and others to help solve some of the global environmental issues we all face together.

The interrelation of core competencies, essential application features and implementation bedrock character ises the discipline and underlines the complexity of the specialty. It is this complex interrelationship that should guide and be refected in the development of related agendas for teaching, research and quality improvement. The WONCA Tree produced by the Swiss College (revised 2011 and 2023) clearly demonstrates this interrelation ship:

4.4 RATIONALE FOR THE CORE COMPETENCIES; ACADEMIC REVIEW AND ANALYSIS

Introduction

The description of competencies is the result of a hi erarchical process. From the principles of the disci pline of general practice, the professional tasks of the specialty of the general practitioner (GP) are derived, and from these tasks follow the core competencies. The order of the classifcation in the core competency list does not imply greater or lesser importance; all are required in the delivery of high quality care in family medicine. They are used to a greater or lesser extent depending on the patient and the problem presented. What is clear is that, as a result of the wide variety of clinical challenges met in day-to-day general practice, they must all be available to the skilled GP, to be ap

plied appropriately.

The Core Competencies

The twelve characteristics have been grouped togeth er into six clusters or domains of competence, and further developed into groups of specifc competency. Each of these can be traced back to the characteristic features of the discipline from which it is derived. Many relate to more than one characteristic. For example the frst competence domain “Primary Care Management” has seven individual competency statements and can be mapped as illustrated in this table (characteristic features are referred to by their letter as used earlier):

Competency statement	Characteristic
PRIMARY CARE MANAGEMENT
to manage primary contact with patients, dealing with unselected problems	a) is normally the point of frst medical contact within the health care system, providing open and unlimited access to its users, dealing with all health problems regardless of the age, sex, or any other characteristic of the person concerned (also h) which is concerned with “undifferentiated illness”)
to cover the full range of health conditions;	a)
to co-ordinate care with other professionals in primary care and with other specialists;	b) makes efcient use of health care resources through co-ordinating care, working with other professionals in the primary care setting, and by managing the interface with other specialities taking an advocacy role for the patient when needed
to master effective and appropriate care provision and health service utilisation;	b)
to make available to the patient the appropriate services within the health care system;	b)
to act as advocate for the patient	b)

The same exercise can be carried out for the remain ing clusters of competencies.

If the competencies for all six core domains are mas tered then the doctor will have the capability of man aging all problems presented in general practice. They apply to all problems regardless of the clinical area concerned and will be used for the management of hy pertension and hernia, chronic back pain and chronic renal failure.

Essential application features

As well as the six core clusters of competence there are three essential features concerning their applica tion; contextual, attitudinal and scientifc. They are concerned with features of doctors, and determine their ability to apply the core competencies in real life in the work setting. They relate to all doctors and are not specifc to general practice, but in general prac

tice they have a greater impact because of the close relationship between the family doctor and the people with whom they work. General practice, as a patient centred discipline, is “high context“, accepting the subjective world of patient health beliefs, the family and cultural infuences in its problem defnition and in the different aspects of intervention. Most other spe cialties develop as “low context” disciplines, wherever possible limiting decision making to objective facts, measurable quantitative information and visual diag nostic techniques.

A consequence of this is that the doctor involves him/ herself as a person in this relationship with the patient, not merely as a medical provider. S/he must learn to understand and use their own attitudes, strengths and weaknesses, values and beliefs in a partnership with the individual patient.

Europe has a variety of health care systems and di verse situations where care is provided by the GP. There are basic cultural (including religious) and po litical differences in the societies and the populations the GP is serving. This may lead to a variation in job descriptions. General practice is the clinical discipline, which more than any other is dependent on societal differences. The GP is the mediator between society and medicine. These factors also impact on the doctor as a person, justifying, clarifying and explicitly sharing these personal attitudes with patients is one of the competencies to be achieved.

Although a high-context and very individually focused discipline, general practice should be as much as pos sible based on scientifc evidence. Using experience in the management of patients remains very important, but should wherever possible be supported by and ver ifed against sound evidence published and collected in medical literature and guidelines. Family doctors be

able to search, collect, understand and interpret sci entifc research critically and using evidence as much as possible.

Critically reviewing experience in practice should be come an attitude that is maintained over the whole professional career. Knowing and using the principles of lifelong learning and quality improvement should be considered as an essential competence.

Implementation bedrock

Policy changes for cultural change, behaviour change, social equity, education and research on sustainable living are needed to reduce the rate of global warming and reduce the carbon footprint of modern living, in

cluding health related activities.

Family Medicine is not unique in having a role to play in this task, all of humanity does, and all health profes sionals in the healthcare sector do too. However, the health sector alone cannot improve the health of the planet, it must work collaboratively with other sectors and with other disciplines, to inform, educate and in

novate.

Medical professionals working in primary care have a special role within healthcare, due to the long-term holistic relationship with patients, the public, from cradle to grave. Family doctors also interact with oth

er health professionals in primary care teams and in hospital services when caring for patients, and during medical education and research activities.

There are actions that GP/FM can take in partnership with patients, and both parties must be informed by scientifc and social determinants of health, and ep idemiology. This evidence can be translated for the beneft of patients, and to improve health literacy and One Health literacy.

The majority of adults in Europe have at least one chronic condition (diabetes, asthma, hypertension, arthritis, obesity etc) and many have several chronic conditions. Many chronic conditions can be treated and even reversed by supporting patients to partici pate in lifestyle behaviour change activities that are evidence-based.

In addition to lifestyle changes, quaternary prevention is an evidence-based concept aiming to protect pa tients from medical harm of overmedicalisation and overintervention where there is a lack of evidence that those actions will improve the outcome for a patient.

Competence and performance

The core competencies are required to become a skilled exponent of the discipline of general practice. However acquiring the competences does not guaran tee that they will translated into the everyday work set ting, that is lead to actual performance. Competence can be defned as the GP’s capability to successfully perform a series of discrete observable tasks in isola tion from actual work¹. In the Miller terminology, com petence is related to what the learner can show when asked or assessed, performance what the learner is doing in daily practice settings².

Thus, competence can be seen as the capability of an individual to act at the required level in a given situa tion. In the Miller triangle the levels ‘knows’ (basic facts), ‘knows how’ (able to apply knowledge) and ‘shows how’ (able to show skills) are related to the concept of com petence. (See fgure 1). Performance can be defned as what a doctor is actually doing in clinical care and communication with patients in daily practice; perfor mance relates to Miller’s ‘does’ level. It is considered highly dependent on existing health care conditions and requirements, fnancial and structural opportuni ties, practice opportunities and support.

Figure 1 – Adaptation of the Miller “levels”

However successfully converting the capability to

perform into actual performance also requires the es

sential application features, which are features of the

doctor, and not of the health system. This can also be

represented diagrammatically:

The essential features of the doctor, his or her atti tudes, attributes and interaction with the health care system and society in which s/he works will determine the level of performance that is achieved. The “does” area in the above diagram is not homogenous, but con tains different levels of expertise from the competent, the profcient to the expert. The interrelation of core competences, and essential features characterises the discipline and underlines the complexity of the specialty, and the ability to synthesise and apply the wide range of competencies in dealing with a patient and problem which defnes the expert general practi

tioner.

REFERENCES

The competences in this document are the starting point for determining the standards for the compe tent specialist in general practice / family medicine. They are applicable in all health care systems and form a theoretical model or framework for teaching and learning our discipline.

The reality of practice may and will differ in different countries, cultures and health care systems, and the tasks that a general practitioner is required to perform may differ. However the competences required to de

liver those tasks should be the same.

1. Ram P, van der Vleuten CPM, Rethans JJ, Grol R, Aretz K. Assessment of practicing family physicians in a multiple-station examination using standardised patients with observation of consultation in daily practice. Acad Med 1999;74:62-9.

2. Ram P. Comprehensive assessment of general practitioners. A study on validity, reliability and feasibili ty. Thesis 1998, Maastricht University.

5. APPENDICES

Appendix 1

Leeuwenhorst defnition 1974

“The general practitioner is a licensed medical graduate who gives personal, primary and continuing care to individuals, families, and a practice population, irrespective of age, sex and illness. It is the synthesis of these functions which is unique. He will attend his patients in his consulting room and in their homes and sometimes in a clinic or hospital. His aim is to make early diagnoses. He will include and integrate physical, psychological and social factors in his consideration about health and illness. This will be expressed in the care of his patients. He will make an initial decision about every problem which is presented to him as a doctor. He will undertake the continuing management of his patients with chronic, recurrent or terminal illnesses. Prolonged contact means that he can use repeated opportunities to gather information at a pace appropriate to each patient and build up a relationship of trust which he can use professionally. He will practice in co-operation with other colleagues medical, and non-medical. He will know how and when to intervene through treatment, prevention and educa tion to promote the health of his patients and their families. He will recognise that he also has a professional responsibility to the community.”

WONCA defnition 1991

“The general practitioner or family physician is the physician who is primarily responsible for providing compre hensive care to every individual seeking medical care and arranging for other health personnel to provide servic es when necessary. The general practitioner/family physician functions as a generalist who accepts everyone seeking care, whereas other health providers limit access to their services on the basis of age, sex or diagnosis.

The general practitioner/family physician cares for the individual in the context of the family, and the family in the context of the community, irrespective of race, religion, culture or social class. He is clinically competent to provide the greater part of their care after taking into account their cultural, socio-economic and psychological background. In addition he takes personal responsibility for providing comprehensive and continuing care for his patients.

The general practitioner/family physician exercises his/her professional role by providing care, either directly or through the services of others according to their health needs and resources available within the community he/she serves.”

Olesen Defnition 2000

“The general practitioner is a specialist trained to work in the front line of a health care system and to take the initial steps to provide care for any health problem(s) that patients may have. The general practitioner takes care of individuals in a society, irrespective of the patient’s type of disease or other personal and social characteris tics, and organises the resources available in the health care system to the best advantage of the patients. The general practitioner engages with autonomous individuals across the felds of prevention, diagnosis, cure, care, and palliation, using and integrating the sciences of biomedicine, medical psychology, and medical sociology.”

Appendix 2

Acknowledgements

WONCA EUROPE is grateful to all those organisations and individuals who have contributed written comments or who have taken part in the consultation processes leading to the development of this document. These include:

Austrian Society General Practice/Family Medicine

College of Family Physicians of Canada

College National de Generalistes Enseignants, France

Danish College of General Practitioners

Dutch College of General Practitioners

European Academy of Teachers in General Practice

European General Practice Research Workshop

European Network for Prevention and Health Promotion in Family Medicine and General Practice

European Union of General Practitioners European Working Party on Quality Assurance The Icelandic College of Family Physicians Malta College of Family Doctors

Norwegian College of General Practitioners

Royal College of General Practitioners, United Kingdom Slovak Society of General Practice/Family Medicine Spanish Society of Family and Community Medicine

Swedish association of General Practice

Swiss Society of General Medicine

WHO, Barcelona ofce

World Organisation of Family Doctors

Dr M Boland

Dr G Buckley

Dr J Horder

Prof. C Lionis

Appendix 3

English Language Defnitions

There is a lot of confusion regarding both the language used about general practice / family medicine8,9 and its interpretation. In order that there can be no misinterpretations or misunderstandings for the purposes of these discussion papers the following terms are defned as follows

General practitioner } Family doctor }	Synonyms, used to describe those doctors who have undergone postgraduate training in general practice at least to the level defned in Title 4 of the Doctors’ Directive.
Primary care physician	A physician from whatever discipline working in a primary care setting.
Secondary care physician	A physician who has undergone a period of higher postgraduate training in an organ/disease based discipline, and who works predominately in that discipline in a hospital setting.
Specialist	A physician from whatever discipline who has un dergone a period of higher postgraduate training.
Primary care	The setting within a health care system, usually in the patient’s own community, in which the frst contact with a health professional occurs (exclud ing major trauma).

Appendix 4

Acknowledgements

WONCA European Council is grateful to all the members of the commission who have taken part in the revision process leading to the minor revision of 2011.

Dr. Ernesto Mola

ASSIMEFAC - Interdisciplinary Scientifc Association of both Family and Community Medicine Italy

Tina Eriksson

President of EQUIP

Denmark

José-Miguel Bueno- Ortiz

Spanish Society of Family and Community Medicine (SEMFYC) International Section

Spain

Professor Bernard Gay

President CNGE University of Bordeaux,

France

Janko Kersnick

President of EURACT

Slovenia

Ravzan Miftode

Romanian National Society of Family Medicine/General Practice

Romania

Margaret O Riordan

Irish College of General Practitioners

Ireland

Dr Paul Ram

Maastricht University

The Netherlands

Appendix 5

Acknowledgements

WONCA European Council is grateful to all the members of the commission who have taken part in the revision process leading to the revision of 2023.

Radost Asenova

WONCA Europe EB, EGPRN

Bulgaria

Oisín Brady Bates

Leader of Planetary Health special interest group

European Young Family Doctors Movement

Ireland

Jean-Pierre Jacquet

EURIPA

France

Zalika Klemenc Ketis

WONCA Europe Honorary Treasurer

Slovenia

Carlos Martins

President of EUROPREV

Portugal

Nele Michels

President of EURACT

Belgium

Andrée Rochfort

President of EQUIP

Ireland

Adam Windak

WONCA Europe EB, EURACT

Poland

The European Defnition of General Practice / Family Medicine WONCA EUROPE 2023 Edition

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