At the end of April, I had the pleasure of being invited to Hiroshima university by Dr Yoshida to talk to the students about primary care. Being a country where patients have direct access to specialists, general practice/family medicine is a foreign concept and so it was up to yours truly to open the students’ eyes up to a life outside secondary care.
During my time working in Japan, I have had to become pretty good at explaining the principles of primary care and the history of general practice in the UK because I have to do it all the time when talking to overseas doctors. My first and foremost advice for those interested in an international career is that you need to know your own system before exploring others because you will become an ambassador for your own country and you don’t want to get caught short.
So, I have kindly summarised what I think you need to know outside the things that you have learnt/are learning at your VTS. You are welcome.
Why primary (health) care?
In 1978, WHO and UNICEF organised a conference and published the Declaration of Alma-Ata. An excerpt of this can be seen below.
The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.
Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.
The Declaration of Alma-Ata states that primary health care is the only way to ensure health and well-being for all. Interestingly, it requires community participation in setting health agendas which is exactly why primary care provides a population-based health care.
Last year, this statement was reaffirmed at the Astana declaration on the 40th anniversary of the Declaration of Alma-Ata but how this will be put into action is another story.
Universal Health Coverage
It’s impossible to talk about health being a human right without talking about universal health coverage (UHC) – how do we make sure that no one is left behind? This means that all members of the population have access to a health service of sufficient quality which does not expose them to financial catastrophe. We have (more or less) achieved UHC in the UK; and the U.S is a famous example of a system that isn’t there yet.
Principles of primary care
The WHO state that the four main features of primary care (which is a subset of primary health care) are:
- First point of contact
- Continuity of Care – focusing on the long-term health of the patient and not on short-term diseases
- Comprehensive care – ability to use a range of services appropriate to common problems of the local population
- Co-ordination of care – able to co-ordinate specialists that the patient may need.
Although we take all of these for granted in the UK, we really shouldn’t because it’s an aspiration for many other health systems. Being the first point of contact and having continuity of care means that develop a relationship with the patient and we know that this is good for outcomes especially for the young and the vulnerable. Being comprehensive and being able to co-ordinate the care means that we give a cost-effective service with very few repetitions of tests. We definitely could be better funded but we really give a good bang for our buck!
The history of UK general practice
A common question I get asked is how did general practice come about in the UK? This is often asked by doctors who are trying to introduce a robust primary care system into their country. There has always been a history of community doctors and the family doctor is nothing new and the evolution of the general practitioner was a gradual one in the UK. In 1911, the National Insurance Act was introduced ensuring that all working men were entitled to free health care. However, it was with the introduction of our beloved NHS in 1948, where everyone was entitled to free health care, that a prototype of general practice was borne. It’s tricky as the introduction of GP was really led by the government and the doctors were the ones dragging their feet!
However, conditions weren’t good and the Collings report was pretty damning about the state of general practice – which was shoddy, not because of the hard-working GPs but, because the system was under-funding primary care in favour of secondary care.
” the over-all state of general practice is bad and still deteriorating.”
” it is neither my purpose nor my desire to defame the overworked and often conscientious doctor who has to suffer the indignities of this way of working.”
For several decades general practice has adapted itself to the growth and development of hospital, specialist, and other medical services ; but ” this process has resulted in the decline rather than the progressive evolution of general practice, and in wide departure from both the idea and the ideal of family doctoring.”
Ho ho ho, not much has changed then in the last 60 years! This report sounds like it could literally have been written just now! Anyway, this report led to the College of General Practitioners forming in 1952 to represent the profession.
Over time, the College has sought to professionalise general practice – with the introduction of the exit exams (CSA and AKT) in 2007 – and to become the voice for general practitioners. Although the stats show that First5’s are the most likely out of all the GP subgroups to get rid of their membership as they don’t see a transactional value in the College’s work, this often leaves me feeling conflicted, given everything that happens behind closed doors to advocate for our professional lives.
Nowadays, there are around 50,000 GPs registered with the GMC and I’m sure I read somewhere that we need 50% or so of our medical graduates to become GPs to keep up with demand (please let me know if this is false as I can’t refind this fact).
A few words about why knowing this will make you a better GP
As you probably have guessed by now, I am a big fan of general practice . Despite the fact that I find it challenging and I struggle with dealing with uncertainty and I dislike the feeling that I’ve just been through the wars at the end of a duty doc day, it’s definitely the end of the healthcare system that I prefer. Knowing why we are here and where we have come from and seeing a world where GPs don’t exist can be an enlightening experience.
I often see quite negative group-think comments on Facebook about both specialists, other GPs and patients. Agreed that some doctors and patients should know better but actually our role as a GP means that we are the first contact for patients so I feel that it is inevitable that they will come to us with the banal mixed in with the medical; the existence of the heart sink is only a reflection of the continuity of care that we are able to provide; being able to give comprehensive care means that we hold the key to services that our patients want – much like bouncers to a club; and being able to co-ordinate care means that we have to occasionally deal with hoity-toity specialist doctors and their bizarre requests and smarmy tones. As primary care physicians, I feel that this is inevitable and an understanding of what is worth changing will help us know what productive conversations to start next.
In general, I think that it also gives me confidence that I am not just a GP. I’ve obviously had that look when divulging my career choice to others and I recently read a report on an RCGP survey performed on medical students about general practice. The part that was most upsetting in this survey are the quotes that were made by specialists about general practice as a career choice that have stuck in the students’ mind. I think my peer group from medical school are better than this and there is a better understanding about the role of the GP as time goes on. These shared learning clinics between GP registrars and specialist registrars in conjunction with compulsory GP rotations for Foundation Years will hopefully change this toxic environment. My hope is that once the more narrow-minded become a minority, these comments will be minimised and hopefully disappear. However, we owe it to ourselves as a profession to wear our badge proudly and to know our place in the health care system which is, essentially, to hold back the tsunami of need from the doors of secondary care.
In times like these, I like to meditate on the health care world that these particular specialist doctors are envisioning where good GPs don’t exist and then I chuckle at this vision of Hades before pressing ‘send’ for my next patient.
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