Memorandum by The Health Foundation (WP
19)
1. EXECUTIVE
SUMMARY
1.1 The Health Foundation welcomed the long-awaited
publication of The Public Health White Paper, which rightly places
real emphasis on the need to improve public health. However, we
are concerned that while the White Paper sets out specific challenges
to the health service to deliver improvements in this important
area, insufficient consideration has been given about how exactly
these challenges will be met. This is particularly the case when
it comes to GPs, who in our view will be key to delivery of improved
public health. Recent research indicates that GPs in the UK are
least actively engaged in promoting better health compared to
their peers in comparable countries. Government policy will have
to address these shortcomings, as well as addressing the role
of patient engagement in improving public health.
2. THE ROLE
OF PRIMARY
CARE IN
DELIVERING THE
GOVERNMENT'S
PUBLIC HEALTH
AGENDA
2.1 The Government's Public Health White
Paper sets out specific challenges to the health service to deliver
improvements in public health. In particular, it refers to the
role of health professionals in educating and equipping patients
to improve their personal behaviours and to manage chronic or
long-term medical conditions (Public Health White Paper, Choosing
Health, chapter 6).
2.2 Consistent with the Wanless report's
"fully engaged scenario" (HM Treasury, 2002), effective
health promotion and disease management are critical components
for matching demand to supply in healthcare, whilst at the same
time improving the nation's health. The success of the Government's
public health strategy will therefore depend on the extent to
which primary care health services promote and maximize patient
engagement.
2.3 A highly functioning primary care system
would actively encourage patients to adopt healthy behaviours
and to self-diagnose and treat minor ailments, involve patients
in treatment decisions, and support them in the active self-management
of chronic diseases and other long-term medical conditions (Coulter
and Rozansky (2004) BMJ: 329:1197-1198). This approach would also
fulfil the Government's policies around choice, responsiveness
and equity.
3. CURRENT PATIENT
EXPERIENCES IN
PRIMARY CARE:
FINDINGS FROM
THE 2004 COMMONWEALTH
FUND INTERNATIONAL
HEALTH POLICY
SURVEY
3.1 The Health Foundation recently analysed
the results of a major international study comparing patients'
experiences in primary care in order to establish how well the
current primary care system promotes better health, disease management
and patient engagement. The seventh in an annual series, the 2004
Commonwealth Fund International Health Policy Survey gauged public
experiences with primary healthcare systems in Australia, Canada,
New Zealand, the UK and the USA. The survey effectively benchmarks
British patients' experiences against those of their counterparts
in the other countries (Schoen et al, Health Affairs (2004)
10.1377/hlthaff.w4.487).
3.2 A mixed picture emerges from our analysis
of the survey data. Whilst British patients face the fewest hurdles
to access primary care, and are generally satisfied with the status
quo, patient-centred care is not the norm, and there are indications
that primary healthcare is still delivered in a paternalistic
fashion. Compared to the other countries in the survey, the UK
performed the worst in relation to advice about prevention, information
about medicines, shared decision-making, patients' access to records
and self-management of chronic disease. These are specific aspects
of primary care provision that require attention if the full potential
of a primary care led service to improve public health can be
realised.
3.3 The survey shows that NHS patients are
the least likely to have a conversation with their GP about weight,
nutrition and exercise—in the survey, only one in four UK
patients (27%) reported discussing health behaviours with their
GPs. The same small proportion reported that their GP had initiated
a discussion about their emotional well being.
3.4 Compared to patient responses from other
nations, Canada and the USA especially, this means that opportunities
to promote healthier lifestyles, reduce the risk of preventable
diseases, and support good mental health are currently being missed
on a significant scale. (See Table 1, below.)
Table 1
IN THE LAST TWO YEARS, HAS YOUR REGULAR GP
PROVIDED ADVICE OR COUNSELLING ON YOUR WEIGHT, NUTRITION, OR EXERCISE?
| Country | Yes
| No | Not sure
| Declined to answer |
| Australia | 38 | 62
| * | * |
| Canada | 45 | 55
| * | * |
| New Zealand | 32 | 67
| 1 | * |
| UK | 27 | 72
| 1 | * |
| USA | 51 | 48
| 1 | * |
| | |
| |
Source: Commonwealth Fund International Health Policy Survey,
2004
3.5 The survey also reviewed the extent to which patients
were engaged in treatment decisions, and how well their preferences
and concerns were identified and acted upon by their GPs. Doctor-patient
communications and interactions are important for all patients,
but especially for people with chronic conditions. Evidence from
other studies shows that better patient engagement and self-management
of chronic conditions improves the patient experience, and even
leads to better health outcomes, more appropriate and efficient
use of healthcare services. (Coulter, The Autonomous Patient,
Nuffield Trust (2002)).
3.6 The survey findings suggest that patient engagement
is not the norm in the UK. Only one in four (27%) reported that
their doctors always tell them about treatment choices and ask
for their ideas and opinions, compared with 41% in New Zealand
and 43% in Australia. (See Table 2, below.)
Table 2
WHEN YOU NEED CARE OR TREATMENT HOW OFTEN DOES YOUR GP
TELL YOU ABOUT TREATMENT CHOICES AND ASK FOR YOUR IDEAS AND OPINIONS?
(PERCENTAGES)
| Country | Always
| Usually | Rarely,
sometimes
or never
| Not sure | Declined to answer
|
| Australia | 43 | 19
| 35 | 3 | * |
| Canada | 36 | 26
| 35 | 2 | 1 |
| New Zealand | 41 | 22
| 31 | 6 | 1 |
| UK | 27 | 15 |
50 | 7 | 1 |
| USA | 29 | 23 |
44 | 3 | 1 |
| | |
| | |
Source: Commonwealth Fund International Health Policy Survey,
2004
4. POLICY ISSUES
4.1 In relation to public health, there seems to be quite
a gap between where we are now, and the sort of health service
the Government would like to see. The findings from the Commonwealth
Fund Survey suggest that, for the UK, we are far behind other
countries in using primary care services to improve public health.
4.2 The Public Health White Paper suggests that a very
wide range of professionals and community members could have a
part to play in promoting healthy lifestyles. But it has very
little to say about the specific role GPs should play. While the
varied NHS workforce can undoubtedly contribute to better public
health, The Health Foundation thinks the place to start is primary
care.
4.3 Government policy for public health should also address
shortfalls in the provision of primary care. The Government has
just finished negotiating a new GP contract, which hopefully provides
adequate incentives for GPs and primary care staff to undertake
more health promotion work. It is surprising, however, that the
Public Health White Paper has so little to say about the vital
role of primary care professionals in improving public health.
4.4 Does the GP contract contain the right incentives
to improve the performance of primary care? Whilst there are incentives
to provide better advice on nutrition, smoking prevention, and
blood pressure checks, it does little to encourage patient engagement.
The Public Health White Paper does not address the role of patient
engagement in improving public health.
January 2005
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