Memorandum by The Royal College of General
Practitioners (PH 74)
PRIMARY CARE AND THE PUBLIC HEALTH FUNCTION
A DISCUSSION DOCUMENT IN RESPONSE TO "SAVING LIVES: OUR HEALTHIER
NATION"
INTRODUCTION
This year has seen:
— the end of fundholding;
— the creation of primary care groups;
— the arrival of Health Improvement
Plans; and
— the publication of Saving Lives:
Our Healthier Nation in England.
All these changes affect the relationship between
primary care and the public health function of the health service.
This document sets out the nature of those changes and their implications.
Although the same issues apply in Scotland, Wales and Northern
Ireland, this document directly addresses Saving Lives: Our
Healthier Nation which is an English document.
BACKGROUND
General practice is and always has been based
on the concept of personal doctoring. The unique doctor-patient
relationship is at the core of our discipline. Often developed
over sustained period of time, it is built on the care of the
patient, the trust that the patient has in their doctor, their
doctor's advocacy for them within the health and social care services,
and the doctor's understanding of that patient, their family and
their community.
When the NHS was formed in 1948 general practitioners
did little more than personal doctoring, focussing on presented
acute and chronic illness. In the last 50 years we have seen a
widening of the scope of the discipline of general practice and
primary care. After the GP Charter in 1966, general practice saw
the advent of primary health care teams and an expectation that
they would play a role in prevention of illness. General practitioners
moved from being reactive to patients to, in addition, identifying
and meeting individual patient needs proactively. The continuing
long-term care of patients with chronic disease became an intrinsic
part of general practice.
General practice, through its registered patient
base and right of referral, holds the only complete life long
health record. It has experience of looking at the health needs
of individuals and populations, and striving to match services
to those needs. General practitioners and members of the primary
care team are part of their local community and have an understanding
of that community's needs, culture and expectations.
Fundholding involved general practitioners and
primary care teams in a range of activities from purchasing to
contracting to commissioning. Those who were involved in commissioning
required to identify the health needs of their population and
to use the mechanisms of fundholding to ensure the provision of
services that most appropriately met those needs.
Personal doctoring has not reduced. General
practitioners undertake about 300 million consultations a year
in the United Kingdom—about 90 per cent of all consultations
within the NHS1. The continuing development of primary care places
new and additional responsibilities within it.
PRIMARY CARE
BASED PUBLIC
HEALTH
The Black Report2, The Health of The Nation3,
the Report on Variations in Health4, the Acheson Report5
and now Saving Lives: Our Healthier Nation6 (and its accompanying
paper on health inequalities7—a response to the Acheson
Report) all reinforce the imperative to address inequalities in
health care. The Royal College of General practitioners has repeatedly
and urgently stressed the need for co-ordinated and effective
action to address health inequalities—our concerns have
not yet been met.
Some illnesses are genetically inherited and
others are acquired by chance. However, there is now clear evidence
that education, socio-economic status, ethnicity, gender, housing,
life events, lifestyle, life choices (including high risks, ones)
and the environment all influence health status and health outcomes.
Many of the major gains in life expectancy achieved in the past
century have been due to improvements in "public health"—supplies
of clean, safe water; sanitation; better housing; clean air; reduction
in smoking; seat belts; motorcycle crash helmets; road design;
smoke alarms . . . While clinical care has made its contribution
(witness the improved survival for many cancers), the significant
effects in population terms, especially in the first half of this
century, have been in the public health field.
In recent years there has been an increasing
conjunction between clinical primary care and the public health
agenda. There has been a growing involvement of general practices
in immunisation, cervical cytology, advice on smoking, alcohol,
diet and weight, early detection and treatment of hypertension
and dyslipidaemias, and the secondary prevention of the complications
of ischaemic heart disease and diabetes.
Clearly such an ambitious agenda is not solely
one for the medical profession, whether in general practice or
public health. It crucially involves patients in understanding
their personal responsibilities for their health and the health
of those around them. Such empowerment can best occur within a
long-term personal relationship, as occurs in general practice.
The emphasis on personal responsibility for health in Saving
Lives is very welcome.
Some of these activities have addressed, mainly
in passing, health inequalities. However, many have, perversely,
widened the divide since their effect is greatest on those with
currently the best outcomes. Better educated patients attend well
person clinics and undergo more screening procedures. The better
off have stopped smoking more than the poorer. Asian patients
may experience linguistic barriers in accessing diabetic care—and
they have a higher prevalence of diabetes.
The new paradigm of primary care based public
health calls for general practice to move from action "down
stream", where the effects of a problem are seen, to "upstream"
where the causes are, whether those causes are strictly within
the disease model or within the wider social, economic or environmental
models. (See Annex for examples.)
To achieve this we must have access to training
for established general practitioners. Perhaps more importantly,
such training must be offered to general practice registrars and
to young principals. The opportunities should include public health
posts within vocational training schemes and attachments for general
practitioners. Places should be funded for general practitioners
to attend MPH courses.
IMPROVING EQUALITY
OF HEALTH
STATUS AND
HEALTH OUTCOME
The health experience of patients depends on
much more than primary care in its current form. Those practices
undertaking a health needs assessment of their local population
have uncovered issues that range far beyond health care. This
is illustrated in the three examples in the Box. In one practice
a rapid appraisal undertaken as part of a health needs assessment
of the elderly revealed that the main problem was social isolation—loneliness8.
However, we must not lose sight of the inequality
that exists, whatever its origin, in health status and health
outcome. Poorer communities experience more ischaemic heart disease
and have fewer surgical interventions (angioplasty or CABG). Depression
and other forms of mental illness are more prevalent in deprived
areas. Black and minority ethnic communities experience poor access
to health services. The "inverse care law" still holds
true. We must strive for services to be linguistically, culturally
and structurally appropriate for the patients we serve.
The overall discrepancy in life expectancy with
social class as illustrated in Saving Lives6 is striking
and is unacceptable. In the early 1970s men of working age in
social class V had approximately twice the mortality of men in
social class I. By the early 1990s the difference was three-fold9.
There is a clear leadership role for general practice in addressing
these differences and this trend.
IMPROVING EQUALITY
OF PRIMARY
CARE SERVICES
One insidious form of rationing is through reduced
access to high quality primary care services10. This can occur
when all the local GP lists are closed, and may be worse when
recruitment problems lead to a failure to fill practice vacancies,
especially in deprived areas. Reduced access can occur when:
— demand overwhelms supply and appointments
are unavailable;
— demand results in shorter and less
effective consultations;
— interpreting facilities are not available;
— choice of male or female general
practitioner is not available;
— a full range of team members is not
available;
— clinical skills are not maintained;
— clinical options are not made available
to patients, including appropriate range of services in the primary
care setting;
— primary care clinicians do not know
of local secondary and social services;
— funding constraints deny access to
necessary treatments;
— waiting lists are lengthy;
— refugees and "difficult patients"
are offered temporary registration.
All those working in primary care have a responsibility
to ensure that all patients have access to high quality general
practice. As a College we will do this through support for:
— high quality vocational training;
— effective end point assessment of
vocational training;
— continuing Professional Development;
— membership by Assessment of Performance;
— Fellowship by Assessment;
— Quality Team Development;
— Quality Practice Award;
— Research Practice Accreditation;
and
As a profession we need to ensure that clinical
governance works to improve care and services in all practices,
encouraging CPD, risk management, availability of services and
quality assurance. We will need to work with the postgraduate
educational establishment to offer support to under-performing
doctors and, if appropriate, nurses.
However, we must ensure that services are not
depleted in those areas with well-developed high quality primary
care. The College argues for a "levelling up" not a
"levelling down". Equality should not mean an equal
share of poor service, but equality of excellence.
Where equality can only be achieved through
investment in local primary or social services, then we expect
that funding to be made available. We cannot fulfil our part of
this action programme, if the Department of Health does not ensure
sufficient high quality general practitioners, practice nurses,
community nurses, health visitors and other primary care team
members. In particular we recognise major problems in recruitment
and retention in deprived and disadvantaged areas, problems that
are likely to become more intractable with time and that require
urgent and systematic action.
IMPROVING EQUALITY
OF HEALTH
AND SOCIAL
SERVICES ORGANISATION
The quality of the local health service organisations,
and the priorities they put on public health issues, has a substantial
effect on the health care delivered to a population. Primary Care
Groups and health authorities must create effective Health Improvement
Plans that target resources at these issues.
By involving all organisations in local (the
locality may be a practice, a town, a county, or a region) health
needs assessment, the inequalities in health status and outcome
can be made explicit and then, subsequently, monitored. If we
are to meet the four key targets for improving health in Saving
Lives6—for a reduction in mortality from cancers, heart
disease and stroke, accidents and suicide—we must combine
clinical care with a population perspective, medical interventions
with social action, early detection with community based prevention
of the underlying causes. This will require high quality local
organisations.
THE PRE-REQUISITES
1. Commissioning based on an understanding
of the local health need and local service provision
Over the last 50 years, and particularly the
past 10, general practice has taken a lead in health needs assessment
and locally sensitive commissioning. Such skills are key to the
new public health agenda. Developments in public health must acknowledge
and build on the current expertise in primary care.
Understanding health needs requires an understanding
of the local culture and the barriers to better health. Some of
these barriers exist in the provision of primary and social services.
Many are social, cultural, economic and environmental. Those who
try to understand health needs from a distance, especially through
the use of mortality statistics, will not grasp the realities
on the ground.
General practice holds an increasing clinical
and social database that offers greater insight into health needs
than traditional statistics. For example, we know how many of
our patients smoke and how much, what ages they are and what morbidity
is associated with that smoking. We know what advise and help
to stop smoking has been given. We know about the uptake of aspirin
in patients with ischaemic heart disease or after a stroke. We
know about the numbers of patients with depression, their treatments
and recovery times.
As we learn to link this information to socio-economic
data, perhaps through small area statistics11, and ethnicity12
we will be able to provide a continuous, monitored insight into
the health needs of our populations. Since the effects of interventions
now (such as the use of aspirin or stopping smoking) will be long-term,
the monitoring needs to be long-term too.
When general practice values its role in addressing
inequalities, it will need the means to act, the resources to
act with and the information with which to monitor change.13 It
will also need resources for the commissioning process—we
are now aware that liaison with colleagues and with public health
specialists takes protected time. If local decisions on priorities,
the nature of services, their provision, and their funding can
be used to focus general practice on this issue, change will occur.
2. Independent public health advice
Primary care cannot deliver this alone or in
isolation. While general practitioners, nurses and health visitors
have been quick to take on the basic elements of needs assessment
and the commissioning of locally sensitive services, much expertise
currently lies with public health physicians. In most areas they
have become isolated from general practice and we need to re-establish
communication with them. Both disciplines have unique skills and
expertise that are complementary.
However, public health physicians have moved
into the field of "management" and as a result are closely
associated with the culture, priorities and practises of the health
authorities. Although their advice should be impartial and evidence
based, fundholding practices have found it difficult to accept
that their advice on commissioning decisions was fully divorced
from health authority pressures.
As Primary Care Trusts (and their equivalents
outside England) are created there is a risk that public health
physicians will become isolated in health authorities. In order
to re-establish their role in the emerging primary care-based
public health function, public health physicians should become
independent of health authorities.
All health service bodies—primary care,
community, secondary care, health authorities—should be
able to contract for the impartial expert advice of these important
health professionals. The RCGP welcomes the acknowledgement in
Our Healthier Nation of the important role to be played by non-clinicians
in the public health function, and the RCGP would wish to work
closely with all experts in the public health field.
3. Independent public health monitoring
If the government, the NHS Executive, and the
public are to understand the health needs of their populations
and to monitor changes, they must have access to impartial evidence
derived from independent monitoring. For this reason the RCGP
welcomes the creation of the Health Development Agency and the
public health observatories. It looks for general practitioner
representation in these new structures.
The public health specialists in these observatories
should be able to use their monitoring, insight and understanding
to inform the health service and the public of health needs, health
status and health outcomes; and to offer advice to those who seek
help in improving the health care for their populations. They
should require local equity audits within Health Improvement Plans.
4. Primary care involvement in the social
dimensions of health
General practice and primary health care teams
have always been involved in social dimensions of health at an
individual level. The new challenge is to be effectively involved
in these social dimensions at a population level. As the three
examples in the Box show, the scope is large. Many practices are
already involved at this level; there is a need to extend this
expertise to all practices. The arrival of new primary care organisations
provides an opportunity to extend primary care tasks to fully
encompass the public health function.
5. Resources
Saving Lives: Our Healthier Nation6 lacks
specific information or comment about resources and this is a
considerable concern to the RCGP. If we are to address inequalities
through "levelling up", we in primary care—and
elsewhere—will need additional skills, new alliances, and
more resources. If targets are to be met, if communities are to
be involved, if risks are to be managed and health equality promoted,
then resources must be appropriate to the task.
Identifying inequality, consensus building,
effective consultation, priority setting, commissioning services,
providing the services themselves, and monitoring all require
resources—in terms of money, skills and time. Perhaps the
greatest resource required is a societal investment in the reduction
of socio-economic differentials. Primary care, if adequately supported,
can mitigate some of the effects of deprivation, but the reduction
of deprivation itself must be a high political priority. There
is a need for the Department of Health to be open with the public
and the professions about how these changes are to be funded.
6. Research, development, dissemination and
evaluation
There is a need for high quality primary care-based
research into the impact of socio-economic inequalities on the
task of primary care; research into methods for addressing inequalities
effectively; dissemination of good practice in commissioning and
delivering the public health function; and evaluation of the policies
and targets in Saving Lives.
CONCLUSIONS
The Royal College of General Practitioners broadly
welcomes the new White Paper, Saving Lives: Our Healthier Nation.
Its thrust is in keeping with the historical development of general
practice. Many practices are already actively involved in delivering
this public health agenda.
If we are to succeed in transforming the ideas
of this paper into action, we must see:
— commissioning of services based on
an understanding of local health needs and local service provision;
— an independent and local public health
service;
— independent monitoring of the public
health;
— increased primary care involvement
in the social dimensions of health; and
— resources appropriate to the task.
Primary care has the registered patient base,
the information systems (based on the lifelong health record),
the experience of commissioning and an understanding of the local
communities. These are sound reasons for general practice being
at the heart of the public health agenda, working in close collaboration
with public health physicians.
The RCGP deplores inequalities in health. It
wishes to work with all parties to ensure that inequalities are
recognised, addressed and reduced. Saving Lives: Our Healthier
Nation offers a real opportunity to do this.
October 1999
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