WONCA EUROPE 2023 Edition 


(Revised 2011 and 2023)


The Key Features of the Discipline of General Practice 

The Role of the General Practitioner  


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 (

Table of Contents 





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.


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.  


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


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. 


1. One Health. World Health Organization. 

2. WONCA Statement on Planetary Health and Sustainable Development Goals. healthandsustainabledevelopmentgoals.aspx 

3. Sustainable Development Goals. United Nations, Department of Economic and Social Affairs 

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.


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.


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. 




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.



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. 

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... 

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 

General practitioners/family doctors are specialist phy sicians trained in the principles of the discipline. They  are personal doctors, primarily responsible for the pro vision 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 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. 



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. 



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 


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


Comprehensive care 

3. Field of activities determined by patient  needs and requests 

4. Unselected and complex health prob lems


Orientation to the patient 

1. Patient centred approach 

8. Continuing management


Comprehensive care 

3. Field of activities determined by patient needs and requests 

4. Unselected and complex health problems


Co-ordination with other services 

9. Coordinated care


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. 



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 


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  


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:// 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:// 

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




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 



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. 



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:




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 




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; 


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;


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


to act as advocate for the patient 




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 


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 



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.



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 


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.


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 


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 


José-Miguel Bueno- Ortiz 

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


Professor Bernard Gay 

President CNGE University of Bordeaux,  


Janko Kersnick  

President of EURACT 


Ravzan Miftode 

Romanian National Society of Family Medicine/General Practice 


Margaret O Riordan 

Irish College of General Practitioners 


Dr Paul Ram 

Maastricht University 

The Netherlands


Appendix 5 


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 



Oisín Brady Bates 

Leader of Planetary Health special interest group  

European Young Family Doctors Movement 


Jean-Pierre Jacquet 



Zalika Klemenc Ketis 

WONCA Europe Honorary Treasurer 


Carlos Martins 

President of EUROPREV 


Nele Michels 

President of EURACT 


Andrée Rochfort 

President of EQUIP 


Adam Windak 




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

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