John Fry -A New Approach to Medicine_ Principles and Priorities in Health Care-Springer Netherlands (1978)

ANew Approach to Medicine ANew Approachto Medicine PrinciplesandPriorities inHealthCare by JOHNFRY FamilyPractitionerandWHOConsultant MTP Published by MTP PressLimited St Leonard's House Lancaster,England Copyright 1978John Fry Softcoverreprintof thehardcover1stedition1978 Allrights reserved.No part of thispublication may be reproduced,stored in aretrieval system,or transmitted in any formor by any means,electronic,mechanical,photocopying, recording or otherwise, without prior pennission {romthepublishers. ISBN 978-94-015-1140-7ISBN 978-94-015-1138-4 (eBook) DOI 10.1007/978-94-015-1138-4 Contents PrefaceVll Health care and itsproblems 2Primary care:aspecial field 17 3 What isprimary care?Content and implications 27 4 Who comesand why?Self-careand primary care 37 5 Work:quantity and quality-manpower policies 49 6The nature and natural history of common diseases 65 7 Cure and care 71 8Prescribing81 9 The hospital-primary care interface 93 10Community social servicesIII IIThe primary careteam II9 12Premises and organization I27 13 Prevention and postponement 135 I4 Education and learning 139 I5 How much care?Present state and futureneeds I45 Index 151 v Preface Medicineisnews.Thereisconstantpublicinterestinhealthand disease;inmedicalmiraclesandinbreakthroughs;inmedical disasters, failures and malpraxis ; in deficiencies and defects ofhealth services;and in the rising costs ofhealth care. Medicine is'big business'. Physicians co me out near the top money earnersinmostmedicalcaresystems.IntheUni tedKingdomthe National Health Service (NHS)now costs over [6000 million a year ($ ro 800 million), a free service that costs every British man, woman and child [120 a year($216)in direct and indirect taxes.But this is lessthan the [500 ($900)a year that medical care costseach person inUSAandWestGermany.Indevelopedcountrieshealthcare costsare approachingro%ofthe grossnational product(GNP).It isbigbusinessalsointhatinBritaintheNHSisoneof thelargest employers;aboutImillionBritonsworkasemployees of the NHS, caringfortheother54millionsandintheUSAthenumbersare 5 millioncaring for2.5millions. The provision of health services isfullof problems and dilemmas. Theseproblemsanddilemmascrossall'nationalboundaries.All countriessharethesameproblemsanddilemmas.Problemsof objectives, of standards, of effectiveness and efficiency, and problems of relationsbetweenthe medical profession,thepublic and govern-ment. Medical care stillisfullof mystique.The medicalprofessionstill tendstobeagreatsecretsociety,withmanysecrets.Manyare secretsbecausesomuch stillisunknownabout healthanddisease. Therefore,many therapiesand lines of treatment and management mustbebasedonunsoundpremises.Muchcrazycareisgivento patients.Muchcareseemslessthanusefulandso meispotentially dangerous. Thisbookistheproductofmanyyearsofactivestudyand Vll PREFACE thoughtontheproblemsof arganizingandprovidinghealtheare. It beganwiththepreparation farthe J amesMaekenzieLeeture of theRoyalCollegeof GeneralPraetitionersin1976on'Common SenseandUneommonSensibility'(Journalof theRoyalCollegeof GeneralPractitioners,1977,27,9-17). My objeetivesinthisbookaretoexaminesomeof theeommon problemsandissuesof healtheareandtoeonsiderso mepossible solutions.Thereareeommonissuesthatallwhoareinvolvedin planningforandprovidingcareareconeerned.Facedwiththe restrietionsintheamountofresoureesavailableweallhaveto decide on: how much care ispossible? howmayprioritiesandallocationsbefairlydistributed? what eare isusefuland what isuseless? whoshouldbetrainedtoprovidecareand how? how much clinical freedom should be given the health professions? whatpublicresponsibilitiesshouldtheseprofessionsacceptin return? what eontrols and directives by planners and administrations are reasonable and tolerable? Therearenoeasyanswerstothesequestionsbutaworld-wide publie-professional debate onthem isweHoverdue. Beckenharn,Kent,1978.John Fry. Vlll 1 HealthCare anditsProblems TheU topiannaivity with which weusedtoviewmedicineand its rolesispast.Nolongercanweaffordthecomfortable,butun-realistic,luxuriesof assumingthattherolesof thephysicianareto healandof thepatienttobehealedandthattheirrelationshipis sacrosanctandmustnotbe interferedor tamperedwith. Such idyllicsituationsneverwerereal.Alwaystherehavebeen problemsof providingandpayingforcareandanxietiesoverits quality and effectiveness.But it isonly in the past generation or two that wehave had the courage tobegin to face factsand realities and appreciate the difficulties and dilemmas of endeavouring toprovide goodcare foreveryone. Atoncewecomeacrosstheinsolubleequationof healthcare, namely, that our wants always will be greater than our needs, which alwayswillbegreaterthanouravailableresources.Expressedin another way, the challenge forusall,users as weIl asproviders, must be to decide what is possible, what is necessary, what should be done, howit can bedoneandby whom? Theissuesof healthcarenowextendbeyondthemedicalpro-fession.It isinevitablethat politicallyandsociaflyhealthcarehas becomeamajordepartmentandinvolvementof allgovernments, because it issoexpensive and sodemanding a public right and since it must, forevermore,be part of everyday politics.Therefore,there willbeincreasinginterestandinvolvementinhealthcareandits organization, administration, provision and quality ofservice by the people,bygovernments,bypoliticians,bypublicandprivate agencies,bytradeunionsandbythemedicalandpara-medical professions, crafts and workers.No Ion ger has the medical profession acontrolling monopoly of decisionsand actionson health care. ANEWAPPROACHTOMEDICINE It may be difficult for present and future generations of physicians tocometoterms with thesenew situations.Important among these are the less important and lesspowerful overall roles that physicians haveandwillhave,inhealthcareandtheincreasingamountof scrutiny and accountability towhichprofessionalmedicalcare will be subjected. The physician isnow but one member of a health team, albeit an essential member. No longer can he, or should he, work alone.From thesoloprimarycarephysicianworkinginisolatedgeographical areas to the super-specialists in complex technological medical units, allphysiciansmustnowworkwithnursesandotherpara-medical colleagues,withsocialworkers,withmedicalsecretaries,andwith administrators,if they are toprovide effectiveand efficientmodern medical and health care. Sincetherehastobefinancialinvolvementinhealthcareby governmentsand/orbysicknessandhealthinsurancefunding agenciesthere willbe increasing concern bythemthat they obtain value fortheir monies that they pay to the medical profession. They willseektoapplymodernmarketingmethodstohealthcareand thismust involveattemptstoassessthe quality and quantity of the health care forwhichtheyarepaying. CHANGINGWORLDS Thelast50yearshavebeenthosewithanemphasisonimproving humanhealthandcomfortsandthesehavebeenattributedto scientific advances and progress. The scientific explosion culminated mostdramatically in developingand setting off nuclearexplosions andsettingmenonthemoon.Ourscientificorientatedsocieties haveassociatedmedicalcareandprogresswithsuchmiraculous breakthroughs.The'man inthemoon'outlookinapublicthatis better educated and informed than ever before has created more and more demands and expectations for better health and more effective treatmentof diseaseandlesswillingnesstoacceptanythingmuch less. More and more monies have been put into medical research of all types.N ewtechnologies,therapies and drugs havebeen developed. Medicalcarehasbecomemorecostlyandmorespecializedthan ever and is provided by a whole spectrum of physicians, from the most 2 HEALTHCAREANDITSPROBLEMS super-specialists and sub-specialists, through more general specialists and specialoidstogeneralists.A medical jungle hasbeen created in which the unwary patient will inevitably take so me wrong paths and get lostwith possibledireconsequences. It ismore necessary than ever before foreach of ustohave a per-sonalphysicianwhoknowsus,knowsthetruestateof theartof medicinewiththerisksandlimitationsaswellasitsscopeand potentials,andaboveall,whoisfamiliarwiththecalibreand intricaciesof thelocalmedicalcaresystemand whocanguidehis patients safelythroughthemedical jungle. Althoughthere isneedtoencourageand support coldscience in thelaboratory,it isevenmoreessentialthat it isappliedcarefully as a healing art for the benefit ofpatients in the wards and consulting rooms. Unfortunatelytheoptimisticenthusiasmof themediamenhas tendedtooutruntruereality.Medicineanditsscope,eveninthe lastquarterof thescientifictwentiethcentury,hasbeenoversold. Lifeexpectancyhasscarcely increasedverymuchformiddle-aged men over the past decade, and the volume ofwork in treating disease facingthemedicalprofessioncontinuestogrow.Weareindanger of creatinganover-expectantpublicwhosedemandsandexpec-tationsforbetter health andcare cannotbemet.Wemusttemper thescienceof theimpossiblewiththeart of thepossible. HEALTH Personalhealthisthegoalthatweallendeavourtoachieveand maintainandhealthcare isthesystemthroughwhichit iscarried outhopefully.Inmostsocietieshealthandhealthcarearecon-sideredashumanrightstobeprovidedbyotherswithaslittle personal effort and responsibility aspossible by the individual. But what ishealth? The definition ofhealth by the World Health Organization(WHO),'astateof completephysical,mentaland social well- being and not merel y an absence of disease', is a si tua tion that israrely achieved by any for any length of time. Health isa rare subjectivestateof mindandanevenmorerareobjectivephysical state. Applying the WHO definitiontorandom sampIes of populations it se'emsthat at any time lessthanro%are'healthy'and that 90% 3 ANEWAPPROACHTOMEDICINE are in astate of active'non-health'though not suffering fromovert diseases(DunnellandCartwright,1972;Wadsworth,Butterfieid and Blaney,1971). NON-HEALTH In a typical year about nine out of ten will suffer one or more illness oraccident.Of theseatleastthreeoutof fourwillbeself-treated. However, in a developed society such as in Europe or North America approximately two- thirds of the population will consult a physician annually.Thisphysicianmaybeafamilyphysicianorahospital doctor. Ofthe population intheUK (and the figuresare similar in USA andotherEuropeancountries),around10-12%willbeadmitted to a hospital ward,15-17% willbe referred to specialist consultants inhospitalsanddinicsand18-20%willtakethemselves,orbe taken,tohospitalaccident-emergencydepartments.Takenasa whole it islikelythat one-third of adevelopedsociety'spopulation willreceivehospitalorspecialistcareinanyyearfornon-health problems and diseases. INDICESOFHEALTHANDDISEASE The battery of statistical indices and data on health and non-health andvitalstatisticsindevelopedcountriesshowcommontrends. Birthratesarefalling,peoplearelivinglonger,theproportionsof elderly people are increasing (to10-20% ofthe populations) and the proportionsof handicapped and disabledare increasing because of medicalsalvage.Infantmortalityandmaternalmortalityhave continued todedine andare goodindicators of socialandmedical advancement.Yet there are no signsof dedine in overall morbidity or inuseof medical resources. The quantity oflife has grown and become extended but there is lesscertainty of the quality of health. WHOSERESPONSIBILITIES? Our endeavours to achieve and maintain health, prevent disease and deal with it when it occurs demand a joint effort from providers and 4 HEALTHCAREANDITSPROBLEMS eonsumers.Responsibilitieshavetobeshared.The individual,the family,theloealeommunityandthenation(state)allhavetheir parts toplay. Promotion of good health and eontrol and management of disease requiremorethanreasonablemediealresourees,withinwhiehthe health professions play their part. The individual has to be prepared tofollowsimplehealthrulesandavoidself-abuse.Hehastotake regularexereise,areasonablediet,maintainanoptimumweight, and restriettobaeeo smoking and alcohol eonsumption.The family asthe basic social unit hasforproviding self-care for minor illnessandcollaborativecarewithother healthresourcesin moremajorandchronicdiseases.Individualsandfamilieshave responsibilitiesintheirselective,discriminatingandeeonomicuse of resources. The local community and the nation have the wider responsibilities inensuringsafewaterandsewageandsanitation,adequatefood supplies,housing,andinprovidingsafeandsatisfyingworkand rewards in areasonableenvironment.They alsohavetheresponsi-bilitiestopromotepreventivemeasuressuchasimmunizationand earlydiagnosisandtreatmentof disease.Suchresponsibilitiesare reasonableexpectationsinamoderndevelopedsoeietyandif they wereachievedthenit islikelythat health wouldimproveand con-tinue to improve. DISEASES Disease isnever static. Within the affeeted person the condition may remainthesamebutoftenittendstoimproveordeteriorate. Diseasesthemselveshaveeertaineharacteristiepatternsof natural history(seepage69).Somearedisordersof ageing,thattendto beeomemorefrequentandmoredisablingaspersonsgrowolder. Some disordersaffect.ehildren and then naturally disappear.Some that affeetyoung or middle-agedadultshavean onset,apeak and aremission.Somesyndromesaremostprevalent intheyoungand theold.Some,oneepresent,remainunaltereduntildeath. Changeshaveoccurredindiseasesoverthepasteenturyin developed societies. Diseases of dirt, deprivation and defieieney have beeomelessprevalent.Theseincludethemajor infeetivedisorders suchastubereulosis,poliomyelitis,measles,whoopingeoughand 5 ANEWAPPROACHTOMEDICINE streptoccal infection. These improvements probably have happened more from social than medical improvements(McKeown,1976). In developed societies certain diseases have increased in frequency, possiblybecauseof environmentalandpersonalfactorsassociated withaffiuence.Inthisgrouparecoronaryarterydiseases,certain cancers,roadtrafficaccidentsandchronicbronchitis. Since we all have to die, ifwe live longer we shall die from diseases of ageingandthesehavebecomemorefrequentinsocietieswhere lifeexpectancy has increased. Another group of conditions is those associated with some inherited factors.Inadditiontothemoreobviousinheritedgeneticabnor-malitiestherearedisordersanddiseasetendenciesandhabitsof behaviourthattendtoruninfamilies.Theold-fashionedterm 'diathesis' should not be despised or forgottenbecause it does depict apredispositiontoemotionalandpsychosomaticdisordersand disorderssuchasmigraine,duodenalulcer,asthma,andvarious skindisordersthat are repeated in successive generations. Then there isanother group of common and weIlnigh inevitable disorders,'normalabnormalities'in fact.Weallhaveour share of minorrespiratoryinfections,ofacutegastro-intestinalupsets,of variousachesandpainsandtraumata,moodchanges,rashesand anumber of other conditions. A system of health care has to be able toprovide care forall these diseasesand forassociatedso ci alproblemsaswell. CARE:PROBLEMSANDISSUES Instrivingtoimprovehealthandcontroldiseasethroughbetter andmoremedicalandother formsof carewehavetendedtoout-striprealismandhavebasedtoomuchonvainhopes,mirages, dreams and illusions. Whilstscientificmethodsandeffortshavebeenencouragedand supported inbasicand clinical research and care,not enough hard scientificmethodologyhasbeenappliedtotestingthevalueor benefitsof alltheseefforts.AsMcKeown(1976)hasnotedamore criticalapproachtoquality of ca reisnecessaryandwemustpose questions: on standards (how weIl we do what we do?) ; on effective-ness(iswhat wedo worth doing?); on efficiency(deswhat wed makebetterusef resurcesthanavailablealternatives?). 6 HEALTHCAREANDITSPROBLEMS With fewbrakes on restrictions on clinical freedom and with little thought giventocostsandappropriatenessof thetherapeuticand investigative measures used, we have tended to adopt a 'gawdsaking' approach(ForGod'ssakedosomething!),with'crazycare'as amarkedfeature.Actionssuchasover-medication,particularly of elderlypatientswithchronicandprogressivedisordersof ageing, over-investigation using expensive and hazardous techniques, over-cutting, in excessiveuseof surgical procedures,and above all over-enthusiastic preterminal carethat prolongsthe finalagoniesbefore death,demonstratethedangersofiatrogenicpseudoscienceas amodernmedical hazard. Goodpersonalcareinourmodernerarequiresmorethanever before common sense and uncommon sensibility and it still requires theapplicationof AmbrosePare'spleamadeovertwocenturies ago,thatwesecktocuresometimes,relieveoftenandcomfort always, to which we may add that we may endeavour now to prevent hopefully. Ratherthangoonwithstridentannouncementsof newsabout medical miracles and breakthroughs there isneedtopause and con-solidateand eventoengage in'negative'health education,of both publicandprofession.Wemusthonestly statethattherearestrict limitations tomedical therapy, that many discomforts and disorders have to be accepted asnon-curable although amenable torelief and thatbetterhealthliesmoreinpersonalapplicationof soundrules of health and environmental improvements than in more and more drugs,surgery,investigationsandother formsof medicalorpara-medical intervention. COMMONDILEMMAS Theproblemsof healthcareareinternationalandintranational, acrossstate,provincialandlocalboundaries.Thereisnosingle answer toevery issue.There are some dilemmasthat are shared by, andcommonto,allsystemsof care. To repeat, we all face the insoluble equation of care with expectant wantsbeinggreaterthan assessedneeds,whichinturnare greater thantheavailableneeds.There isnosystemthereforewherethere isa sufficient supply ofhealth care resources.The relative shortages and deficiencies emphasize the need for effective planning in making 7 ANEWAPPROACHTOMEDICINE the best use of available resources and ensuring wherever and when-everpossiblefairandequabledistribution,geographicallyand sociaIly,asweIlason medicalgrounds.There havetobepriorities that shouldbe spelledout andagreedand acceptedbypublic arid professionand somerationing hastobeapplied. If ahealthcaresystemistoworkweIlandmakegooduseof its resources then it isinevitable that some controls and directives must be applied to planning and to everyday work.Duplication has to be avoidedandgoodstandardsofcarethatarealsoeffectiveand efficientmust beensured. Acceptance of controls and directives isanathema toan indepen-dent medical professionthat cherishescomplete clinical freedom in caring forpatientsbut acompromisehastobearrivedat because, as noted already, the high cost ofhealth care which requires govern-ment or quasi-government involvement in meeting costs me ans that some controls and directives are inevitable and willnot only persist but increase. A modusvivendi between profession and administrators isnecessary foranysuccessfulhealthcaresystem.Mutualunderstandingis necessaryfrombothsidesandreliableandup-to-dateoperational data and factsare essential if planning istobe effectiveand und er-standable.Such factualda tahasbeenmissinginallsystemssofar and isone of themain reasons why problemsexist in planning and administration. Data is required to show what care is being provided, for whom and by whom, for what conditions, how, where and when andwithwhatresults?How weHaretheservicesworking?Isthe care being given worth while and are the best methods and resources being used? Research to answer such questions must be built into every system of careandcollaboration inprovidingreasonableamounts of data hastobeanagreedcondition of serviceby theprofession. LlMITLESSWANTSANDDEMANDS The wantsanddemandsof consumersof health careresourcesare limitless, and are exploited by the public and the profession. There isavacuum of sophistication in health care.There is,and always will be, enough work for the medical profession. There never will be astate oftotal health for aHwhere no diseases exist and where 8 HEALTHCAREANDITSPROBLEMS there is unemployment of nurses and physicians - assuming that there isenough money topay them fortheir services.Once major disease problemsarecontrolled - inthepastthesewerethegreat infective diseases such astuberculosis, poliomyelitis, diphtheria, scarlet fever, measles,smallpox,typhoidandcholera,andinthefuturepossibly cancer - there willbe no respite forthemedical profession.Into the vacuumthat iscreatedwillco meflowinginawholerangeof new andpreviouslyunappreciateddisorders(FigureI. I).Thus,since themajorinfectivediseaseshavebeencontrolled,intotheirplace havecomemorepsychiatrieandpsychosocialdisorders,coronary arterydiseasesandrequestsforcareof previouslyacceptedand enduredachesandpains.Thisalwayswillbeso. MINOR SELFCARE PRE-SYMPTOMATIC HEALTH Figure 1.1Vacuum ofsophistication. MEDICAL CARE SELF-CARE OR NO-CARE The British National Health Service (NHS) was planned originally onthefalsepremisethatoncethemajorphysicalandsocialillsof the British post-war society of the1940S and I950S were corrected by newWelfareState,thentheneedsfurcare willbecomelessand its costswillfall.Howwrong werethenaiveoptimists! 9 Al\:EWAPPROACHTOMEDICINE COSTEXPLOSION TheexperiencesoftheNHShavebeenthatthereisanalmost bottomless pit ofhealth care into which as much money and resources can beput and utilized. The expenditure on the NHS has increasedI3-fo1d in the 25 years, 195 1-76,andevenwhenreducedtotakeaccountof inflationthe increasehasbeenalmost4-fo1d(Figure1.2). 6000 5000 4000 f.million ($2 million) 3000 2000 1000 195119561961 - UKNHSExpenditure ,,-- Cast at1950 prices 1966 YEAR Figure 1.2Costs of theBritishNHS. 19711976 Such escalation of costsof health carearecommontoall systems andtheyraisethequestionof howmuchanynationcanaffordto pay forhealth care. Ta what high levels can such costs be allowed to climb?HowcantheybecontralIedandby whom? 10 HEAL THCAREANDITSPROBLEMS In1978the annual cost ofthe British NHS averaged out at {,120 ($240)per person.However in West Germany and USA the annual costof healthcareaveragedalmost {,500($ 1000)per person. HEALTHCARESYSTEMS Thereisno'best-buy'singlesystemofhealthcarethatcanbe introduced toand applied by allcountries.Although health care is asoldasmankindtheconcept of organization of health care isbut 25yearsold.Eachcountryhasevolveditspatternsof healthcare basedonitsownhis tory,culture,politicalphilosophies,economics and wealth, education, religion, geography and resources. Evolution ratherthanrevolutionhasbeenthekeynoteinwhichnational systems ofhealth care have emerged. Whilst it is difficult to agree on any grouping of systems, Bridgman(1972)has suggested a practical onebasedonadministrationand legislativepatterns. 1Countries of westerncontinentalEurope(excluding Scandinavia)andLatinAmerica Theaxisof administrationisRomanLaw.Thehospitalsystemis based on local government but there are also private hospitals owned byvoluntaryreligiousbodiesorbyprofit-makinginvestors.The medicalprofessionisindependentandcombinesprivatepractice with feesfromsocialsecurity schemes.There are frequent disagree-mentsbetweenthemedicalprofessionandthesocialsecurity schemesoverratesof payandconditionsof service. 2USA Mediciil care intheUSA isbased on free-enterpriseand individual freedomofaction.Apluralisticnon-systemsystemhasevolved. There isamixof government involvementand it isestimatedthat 40%of health care costsare nowpaidby federaland state govern-ments. The hospitalserviceisamixtureof privatevoluntary,Veterans Administration,communitypublichospitalsandthefederalhos-pitals.Personalcareisonaprivate feeforservicebasis,many fees being subsidizedthrough 'pre-paidinsuranceor throughtheMedi-care and Medicaid schemes forthe elderly and socially deprived. II ANEWAPPROACHTOMEDICINE Thewholequestionof thefuturepattern of theUShealthcare systemisunderdebateanddiscussion,asithasbeenforthepast generation. 3Seandinavia andtheUnitedKingdom(NHS) These systemsare planned at central government level,but there is decentralizationtoregional,areaanddistrictlevelsformany servicesintheNHSandtocountylevelsinScandinavia.Social security isuniversalandunder it comprehensivehospitalcareand personalhealth servicesareprovided. In theNHS general practitioners are paid by capitation feesand by feesforcertain items of service,and hospitalphysicians are paid by salaries on asessional basis.In Scandinavia there isamixture of payments through salaries and re-imbursedagreed feesforservices. SomewhatsimilarsystemsexistinCanada,NewZealandand Australiabutthereislesscentralization of planning andthesocial security benefitsaremuch lesscomprehensive. 4Socialist countries IntheUSSR,EasternEurope,China,Cubaandothersocialist countriesthe characteristic featureisthemerging of allhealth care activities with a vast national hierarchical system in which primary care,hospitalservicesandpreventiveca rearecombined(seeFry, 1969). 5Developingcountries with historie andeulturalpatterns stillinforce There isa large number of countries with historie civilizations which are now classified as'developing'. Their health care systemshave to take account of their old roots in creating modern health services. ThusinIndia,Pakistan,Thailand,theArabStates,Turkey, Philippines, and evenJapan, the newer influences ofSocial Security and other schemeshavetobeadaptedtoancientprinciples. 6Developingcountries whose patterns wereimposedby eolonialsystems Most ofthese are in Africa, south ofthe Sahara, but some are in Asia and Oceania. 12 HEALTHCAREANDITSPROBLEMS The systemsimposedwerepublichospitalsthat weremainly for thecolonialarmedservices,nursinghospitalsandhealthposts. Rural areas where most people lived were cared forby paramedical aides.The emphasismostrecentlyhasbeentoencourage self care andprimarycarein:theruralareasratherthansupportmore expensivehospitalsand specialist servicessitedinthecities. LEVELSOFCAREANDADMINISTRATION Whatever the systems of care,there are within every system certain common and inevitable service levels ofcare and administration with similar roles and functions (Figure 1.3). Using such levels it is possible to compare the ways in which the various systems organize such care and administration.Each level isrelatedalsoto sizesof population andtotheexpectedgradesandtypesof diseases. Size of Population 500 000 - 5 000 000 Family physicianLocality SelfcareFamily CareAdministration Figure 1.3Levels of care and administration. FLOWOFCARE The ftowof care in any system(Figure1.4)starts within the family andthentherearevariationsateachinterfacebetweenthelevels of care.Thus intheUK undertheNHSthereisin factonesingle 13 ANEWAPPROACHTOMEDICINE mainportalofentryintothehealthcaresystem,thegeneral practitioner.It ishe who controls the next interface when herefers hispatients to specialists in the hospital service.In the USA with its more pluralistic system, the family has freeaccess to the whole range of specialoids(paediatrician, internist,psychiatrist,OBC,etc.)and truespecialists.IntheUSSRthefamilyiscaredforbythelocal polidinic,wheretheprimarycareisprovidedbyspecialoids, paediatriciansandtherapists(foradults)andinthelargerpoli-clinicsthereareavailablespeeialistssuchassurgeons,OBC, ophthalmologistsandothers.Hospital eare isgivenbyyetanother set of specialists. In a developing eountry there is no ehoiee and there may benoaccessibleservicesavailablelocally. Family Primary Med ica I Care General Specialists Hospital (lnPatient Care) UKUSAUSSR 111\ /1\ (0000000 SpecialoidsSpecia 10 ids /1\ 1I j Hospital 000000 OutPatient Department SpecialistsSpecialists \lI \11 \1/ 1-11

I p= PaediatricianI = InternalMedicineQ=OBG Figure 1.4Flow of care. BASESFORASOUNDSYSTEMOFHEALTHCARE Developing Country HEAlTH WORKER I HOSPITAL Whilstcertainminimalresoureesareneeessaryinanyhealthcare system there are other factorsand featuresthat require noresourees andlittleexpensethat make forasoundsystem. HEAL THCAREANDITS There hastobe a plan with clear objeetives and reasons forthem. The plan hastobe developed on reliable operation al data and faets andtheireolleetionmusthaveahighpriority. Oneenational,regional,area,distrietandloealityplanshave beenprodueeditisneeessarythatextensivepublieedueationand informationexereisesbeundertakentoexplainthemeaningsand implieationsof theplansforeveryone,theprofessionaswellasthe publie.Anunderstandingof eaehone'srolesandresponsibilitiesis important. There hastobe leadership,eontrols and direetives,to ensure that resourees ean be employed usefully, eeonomieally and to good effeet. References Bridgman,R.F.(197'2).In].FryandW.A.].Farndale(eds.),International . MedicalGare(Lancaster:MTPPressLimited) Dunnell,K.andCartwright,A.(1972).Med!cineTaken,PrescribersandHoarders (London:RoutledgeandKeganPaul) Fry,].(1969).MedicineinThreeSocieties(Lancaster:MTPPressLimited) McKeown,T.(1976).TheRole01 Medicine(London:NuffieldProvincial Hospitals Trust) Wadsworth,M.E.].,Butterfieid,W.].H.andBlaney,R.(1971).Healthand Sickness:theGhoice01Treatment(London:TavistockPublications) Furtherreading Bryant,].(1969)'HealthandtheDevelopingWorld(IthacaandLondon:Cornell University Press) Douglas-Wilson,I.andMcLachlan,G.(eds.)(1973).HealthServicePerspectives (London:TheLancetandTheNuffieldProvincialHospitalsTrust) 2 Primary Care: ASpecialField Thelevelof primaryprofessionalcareisakeytomedicalcareas awhole.Notonlyisitakeybutitcontrolsthequalityandthe quantity of careattheother levelsof care.Placedasit isbetween self-carebyindividualsandfamiliesandspecialistcarebasedon expensivemoderntechnologies,itactsasadominant inftuenceon the use of resources. Primary professional care hasto exist in all systems of care and it has certain common roles, features and objectives.The systems may differ but within national and international variations these common factorsareevident.Primarycarehasbeenaneglectedfielduntil recently. It has existed as long as health care itself.There always has been someone somewhere who acted asthe professional of firstcon-tacttowhomthesickturnedtoforca reinthefirstinstance.Yet somehowithasnevercaughttheimaginationof thepublic,pro-fession,planners or politicians.It hasdealt withthemore common disorders that commonly occur and less often with the rare situations that rarely happen.Medical students, taught asthey are in medical schoolssitedinlargeteachinghospitalsstaffedbyspecialistsand super-specialists,getapervertedanddistortedviewof thecom-munity's health needs and thisisin spite of the factthat about one-half of all medical students in all medical schools in all countries will becomeprimaryphysicians,thatis,providingfirstcontactand continuing care totheir patients. Thereisnosingleprototypeprimarycarephysicianthatexists but inallsystemsheisrecognizable fromhisroles.Thus,whilstin the UK the general practitioner is a clearly defined physician within 17 ANEWAPPROACHTOMEDICINE the organization ofthe British National Health Service, in the USA the roles of primary care are carried out by a mix offamily physician generalistsandspecialoidssuchasinternists,paediatricians,psy-chiatrists,obstetricians,gynaecologistsand evenso mesurgeons.In theUSSRprimarycareisverydefinitelyorganizedandbasedon specialoidpaediatriciansandtherapists(internistsforadults)in urban policlinics and on para-medical feldshersin rural areas(one-halfofUSSR isstillclassifiedasrural).InWestern Europe there is thetraditionofsingle-handedfamilyphysiciansworkingalone, althoughthetrendtowardsgrouppracticeandpartnershipsis spreadingfromtheUKtotheN etherlands,WestGermanyand Scandinavia.InSouth Americathere isagreat differencebetween freeaccess('free'if onehasmoney topay)toarangeof specialists and specialoids who are prepared to give primary care; forthe poor there are only thebeginnings of an organized primary care service. Likewise in other economically developing countries early emphasis onhospitalsandprestigespecialtieshascreatedarelativeneglect of primary care that now isbeing slowly corrected by training para-medicalworkerstoprovideprimarycare.Alltheseworkersmay provide primary professional care that include many ofthe roles and functionstobe described. Aftercenturiesof internationalneglectof primarycarethereis nowasuddenexplosionof interestfromplannersandpoliticians. HeadedandledbytheWorldHealthOrganizationithasbeen realized that primary care has a vital, inevitable, important and key roletoplay ineconomic,efficientandeffectivehealthcare. Economicbecauseitismuchcheaperthancareprovidedin hospitalsbyspecialists.IntheUKgeneralpractice,althoughits numbers represent about one-half of all physicians,accounts forless than 10% ofthe NHS budget. Ifit can be efficient then primary care canprotectthehospitalandspecialistservicesfromunnecessary work.If effective it can restrict its own work tothat which isworth doing. WHATISSPECIALABOUTPRIMARYCARE? For those who have not given thought tothe matter,there isa need to make a case forthe special nature of primary care and for special attentiontobe giventoit. 18 PRIMARYCARE:ASPECIALFIELD Notonlyaretherolesandfeaturesof primary caredistinctand different fromthose ofhospital-based specialties but its methods and techniques of diagnosis,care and .management of diseaseand prob-lemsalsohaveadifferentemphasisbecauseof thenatureof the conditionsand problemsencountered(seeChapter 3). Untilrecently,primarycarehashadnoplaceinthemedical curriculum nor did it have any solid scientific foundations or co re of knowledge based on research. Now suddenly, over a decade, depart-mentsof primary care,generalpractice,familymedicine,or other title,havebeencreated,establishedandfundedinmanymedical schools in the UK, USA, Canada, Australia, New Zealand, Nether-lands,Belgium,Scandinavia,Austria,WestGermanyandSouth Africa.Notably,therehavebeennodepartmentsof primarycare created in USSR and other socialistand developing countries. If primary care istocarry out its key roles,improve, develop and expand then there hastobeamuch greater input into and support ofteachingandresearch.Teachinginundergraduatemedical educationmustincludeaperiodof specialvocationaltrainingfor thosewho wishto enter primary care and there must becontinuing educationofestablishedpractitioners.Researchhastoinclude operation alqualitativeinvestigations,experimentsandtrialsto decide on the best methods and techniques of care, as weIl as clinical and basic scientific works. ROLES Primary care hasmany roles within a health care system.Above aIl ithastoprovideareasonableavailableandaccessibleserviceto peoplewhenthey firstrequireskilledcare. Those working in primary care have to be trained, supported and encouraged toprovide care forproblems, situations, conditions and diseaseswhich do not require specialist facilitiesor experience. There ismuch moreto goodhealth and medicalcarethan diag-nosis and treatment of a specific disease.More than medication and physical therapies there are required total care ofthe sick individual and his family within the community. There are many social security services,rehabilitativeandvoluntaryservicesandotherfacilities available in the community that can be brought into action to assist those who needthem. 19 ANEWAPPROACHTOMEDICINE 1tshouldbeoneof therolesof primarycaretoins ti gateand co-ordinatethemanyandvariouspara-medicalcommunityser-vicesthatmaybeavailablenotonlyfortheindividual'sandthe family'sgoodneedsbut alsotoensurethat they are not misusedor wasted. Sound localknowledgeand long experienceshouldenablethose working inprimary caretomanipulatethelocal servicesavailable tosuittheindividualpatient'sspecialneeds,specialcircumstances andspecialpersonality.Differentindividualsandfamiliesmay requiredifferentservicesanddifferentspecialistswithwhomthey mayrelatebest.It istheprimaryphysicianwhohastoselectthe specialist whom he feelswillprovide thebest care forhispatient. It may be that apatient with aduodenal ulcer may be best treated by surgeonAratherthanbysurgeonB,notonlybecauseofthe surgeon'sskillsandexperiencebutbecauseof hispersonalityand attitudes.It maybethat apatient with aseveredepressionwillbe best referred to psychiatrist X who isknown to favour intensive drug therapy rather than to psychiatrist Y, who believes in slow and long-term psychotherapy. It may be that Mrs M. is a proud and indepen-dent old lady who lives alone and who will soon need horne help and hornenursingifsheistobeabletocontinueherindependent functionalexistenceathorne,butherpersonalphysicianwillbe aware fromtheyearsthat hehasknownher,that thesituation has tobemanipulatedslowlyandtactfullybeforesheacceptsthe serVIces. It isfalseeconomyforahealthcaresystemtoemphasizethe specialistandhospitalservicesandneglectprimarycare.It makes much more sense to create and support a sound level of primary care in order to protect the more expensive specialist levels from unnecess-ary work on inappropriate conditions.It ischeaper tokeeppeople out of hospitalsandinthecommunitythantoallowthemfree,or relatively free,accesstothe former. Primary ca re has the role of acting as the protector of the specialist hospitalservicesfrominappropriatepatientsandasprotectorof patientsfromspecialistsandhospitalswhomay,becauseof their inexperienceandlackof knowledgeof theindividualandfamily, undertakeunnecessaryandwastefuldiagnosticandtherapeutic procedures. 20 PRIMARYCARE:ASPECIALFIELD FEATURES Therearecertaindefinablefeaturesof primarycarethatapplyin mostsystems.Inadistrictof 250000personsinawell-populated citytherewillbealargedistricthospitalorperhapstwodistrict hospitalsprovidingspecialistconsultingandin-patientfacilities. Within the same district there willbe,in a developed society,about 100primaryphysiciansworkinginthecommunityoutsidethe hospital. They may work as solo independent practitioners, they may work in groups and they may work from a health centre or policlinic. However they work or are organized, there are the following features of theworkthey doandcarethattheyprovide. 1Smallandstatic community In developedsocieties it canbe reckonedthat there isone primary physician to between 2000 and 3000 persons. This applies to the UK, USA,Canada,USSR,Netherlands,Belgium,France,Denmark, Norway, Australia,New Zealand and South Africa.Whether this is the right proportion is not certain (see Chapter 5), since it depends on factors such as work-Ioad, methods and techniques and time available, but thefacts are that this is what proportions are now and have evolved in all these countries more or less spontaneously and haphazardly. In most places whereprimary care isestablishedthepopulations tendtobefairlystableandstaticwithnottoomuchchangingof physiciansandpatients.IntheUKabout10%of thepopulation moveshouseeachyear.In theUSAtherateisdoubleat20%.In certaindistrictsandplacesthereismoreorlessstability.Thusin settled rural districts few persons move at any time, whereas in many largecitycentresthereisaconstantlymovingpopulationdueto social insecurity. The significance of these two features - a small and static population - is that the physician and his team in primary care isable to get to know most ofhis patients well, particularly as in any year some70%of hispatientswillconsulthirnoneormoretimes eachyear,andhewillseerepresentativesof 90%of families.Of course, where primary care is provided by an ad hoc system of the local hospital emergency roomthennosuch stability and continuity are possible.Norisitpossibleyettoachievesuchcareindeveloping countries where in some regions there may be only one physician of any type,primary,secondary or tertiary,to250000 persons. 21 ANEWAPPROACHTOMEDICINE 2Available andaccessible If satisfactory primary care isto be provided then it has to be readily accessibleandavailable.The peoplehavetobeabletogettothe primary care unit and the physician or other primary health worker has to provide a 24-hour service. There have to be primary care units withinpram-push distance of mothers with children or oldpersons or there has to be a transport system or service provided or available totakethesicktherewhennecessary.Attentionmustbepaidto accessibility in planning. A24-hour availability hastobe provided also.This may haveto beprovidedby a solopractitioner but more usually cover isshared byrotasbetweencolleaguesorthroughcommercialdeputizing serVIces. 3First-contact care Extramedicalandsocio-medicalskillsarerequiredtomakethe initialdiagnosiswhenapatient firstseekshelp.Not onlyareearly symptomsvagueandunformedandsignsfragmentaryorabsent, but the dimension of time has not helped yet in defining the natural pattern ofthe condition. The primary, orfirst-contact, health worker hastobeprepared tomakeatentativeassessmentand diagnosisof thepatient'spresentingproblems.It isnosignof failureorin-adequacy,onthepartof thephysician,totemporizeandaskthe patienttoreturninafewdaysforre-assessment.Becauseof the natureoftheconditionsencounteredinprimarycare(seealso Chapters3and4)many willbetransient,minorandself-limiting and many willremainas'symptoms'withnoprovenor confirmed (byinvestigations)diagnosticlabels - cough,backache,headache, dizziness, dyspepsia, sore throat and others must be accepted as such and providing that on follow-upthey clear and the patient recovers thenno furtheractionsneedbetaken. The primary physicianisin an important position inrelationto early diagnosis and assessment.He has to decide: what ispotentially seriousandwhatisminor;whathastobede'altwithurgently, immediatelyandspecificallyandwhatcanwait;canbe manage and what has to be referred to a more specialized colleague; whatdoeshehavetofollow-uphimself or whatcanhesharewith amember of hisownprimary careteam. 22 PRIMARYCARE:ASPECIALFJELD 4Long-termcare Withinastableandstaticpopulationtheprimaryphysicianoften provides care forhispatients formany yearsand hecomestoknow hispatientsweIlandtheyhirn.Thisisaveryspecialfeatureand benefit of primary care. On a typical day probably no more than one ortwoof the20,30,40or50patientsthathewillseewillbenew patients.Theother90%pluswillbeoldpatientswhomhehas known forso metime.Infact,primary care isacontinuing 'follow-up clinic' for the 2000-3000 persons for whom the primary physician provides long-term care. He comes to know them weIl as individuals, membersof families,workersand localcitizens. Notonlydoeslong-termcarehelpinprovidinggoodpersonal care it alsogivesthe physician very special opportunities toobserve andstudythenaturalhistoryofthecommondiseasesthathe encounters. 5Content of diseaseproblems Theprimaryphysiciancanonlymeetandmanagethosediseases and problemsthat can occur in apopulation of 2000-3000 persons. Theseareinevitableepidemiologicalandstatisticalfacts.Hewill deal with the common diseases that occur commonly and only rarely withthosethathardlyeverhappen.InChapter3theexpected numbersarediscussedbutinevitably,andperhapsfortunately,he willspendhisprofessionallife-timemanagingminorailmentsand helpinghispatientslivewiththeircl1ronicdisordersmorethanin copingdramaticallywiththeoccasionalmajorlife-threatening situations.Hewillbeaskedbyhispatientstohelpthemwitha varietyof personalandfamilyproblemsandwitharangeof social pathologiesthat are not withinthepages of thestandard textbooks of medicineandwhichscarcelyimpingeontheworkof hospital specialist practice. OBJECTIVES Theobjectivesof primarycare,ascareinallmedicalandhealth workmustbe,areto'euresometimes,torelieveoften,tocomfort alwaysand toprevent hopefully'. 23 ANEWAPPROACHTOMEDICINE It isimportanttostressthesometimesinanattemptto'cure' . Mostdiseases,disordersandproblemsof humanbeingsare'non-curable'.They are,or may be,self-limiting,benign and short lived and are best managed by relief and comfort.Many chronic disorders of ageingand degenerationare inevitableand whilstgreatly bene-fitedbypersonalsupportandcare,andrelief bymedicationand other measures,heroicattemptsatcuremay causemoreproblems thanbenefits.Evenwithmajorlife-threateningdiseasessuchas cancerandheartdiseaseswemustbewareagainstmakingthe therapymoregrievousandunpleasantthanthedisease. 1'n our enthusiasm to treat or manage our patients be it forcure or relief orprevention,or giveanymedicaladvicethat may interfere with normallife, weshouldalwaysaskourselves,asphysicians: IIstheconditionnormalor anormal abnormality of lifeandtobe accepted as such? 2Istheconditioncurable,thatis,howfarshouldoneattemptto achieve what may be impossible? 3Istheconditiontolerablefortheindividualpatient?Tolerance of pain,suffering,disability,anddiscomfortarevery variableand care and therapy must be moulded to individual requirements. 4Istheconditionpreventable?Whilstitisrightthatemphasisbe made in preventing diseasesletusnot impose unproven restrictions to normallife or add unproven measures in falseattempts to prevent diseases.Betterandlongerlifeismostlikelybyfollowingnormal andsimplehealthrules,suchas:regularexercise;nosmoking; moderation in eating and drinking aIcohol;weight control; regular sleepinghabitsandavoidanceof stresses.Thesearesosimple,yet so difficult to follow,and so weIl understood by most people that one wondershowmuch time,effortandmoneyneedbe spent on other unprovenpreventivemeasures.Themedicalcheck-up,screening of populations, faddiets,vitamins and other pseudo-measures have little soundbasisforuseinhealth care. Objectivescanberelatedalsotowhat primary care can achieve fortheindividual,the family,thecommunity andthenation. For the individual primary care should offer a continuing personal service by a primary health team that may incIude physician, nurse andsocialworker.Self-care,self-helpandself-responsibilityfor PRIMARYCARE:ASPECIALFIELD healthanddiseasepreventionmustbeencouragedthroughaform of continuingpersonalhealtheducationof patientswheneverthey havecontactwiththeprimary careteam.Patientswillbehelped, educated and trained to make proper and best use ofhealth resources. Attemptsmustbemadetodealwiththe wholepersonandhis(or her)problemsandthisiseasierinthecontextof primarycare because of our knowledge of our patients. The family must be cared fix asthe basic social unit and the broad pathologies offamily life must be appreciated and understood. They relatetotheinterpersonalrelationsof allwhocompriseafamily. Stresses and frictionbetween husband and wifeare potent causes of symptomsandproblemsinprimarycareandthereisscopeand opportunityforfamilyphysicianstoassistintheirresolution. Relationsbetweenparentsandchildrenmaybecomestrainedand leadtostresssymptomsinparentsaswellasinyoungchildren.At the other end of the age-scale the care of elderly parents, uneles and auntsor evengrandparents isnow acommon causeof intra-family pathology with problems of what care and who istoprovide forthe elderly. The objectives of primary carerangebeyondthe individual and family into the local community. Within the community the primary care healthteamsmustplantoworktogether and in eollaboration and co-operation with other teams to provide a service to the people thatissound,accessibleandavailableataBtimes.Thisrequires arrangementsforout-of-hourscoverandeloseworkingtogetherto meetemergenciessuchasepidemicsandnaturaldisasters. Primary carehastoextendthe frontlineof health care fromthe consulting room,the health centre, group practice and hospital into the community. Through health education bad personal, family and community habits shouldbecorrected,environmentalhazards put rightand vulnerableat-riskgroupsdefinedand helped. Withinallsocietiesandcountriesprimarycareservicesmustfit into apattern within a health care system.The formsand details of the systemsmay vary but within them aBthere are certain national responsibilitiesforeveryone.Bestusehastobemadeof national resources.Was teandextravagencemustbeavoided.Toachieve bestresultstherehastobeanationalsystemof datacollection, analysisandapplicationtodiscoverwhatiseffectiveandefficient and what isnon-effectiveand non-efficient. ANEWAPPROACHTOMEDICINE SCOPEANDOPPORTUNITIES Primarycareprovidesspecialopportunitiestopracticetheartof medicine,touseitscraftsandtoaddtoitsscientificknowledge. In our scientific age it is more important than ever that the potent, and potentially dangerous, investigations, drugs and other therapies are used with the greatest care and discrimination.Never before has the medical profession had such tremendously powerful therapeutic andinvestigativearmamenteriumavailabletocureandrelieve humandiseaseandsuffering,butwithsuchgrowthinpowerand scopetherehave grownalsopossiblerisksand sideeffects.It isthe duty of all physicians, but especially the personal primary physician, tobeselectiveandcareful inhisuseof modernmedical machinery and drugs.Patients have to be protected asweIl astreated. Thecraftof medicinehasbecomemoreskilful.N ewandbetter toolsfordiagnosisand treatment are available and are being intro-duced daily.It isvery necessary that the best and most appropriate moderntoolsandtechniquesbeintroduced intoprimary careand thatitspractitionerslearnhowtoapplythem.Butwehavetobe certain that newtoolsand techniquesarebetter and saferthan the oldbeforetheyareacceptedintoregularcare. Primary care offers a new-old field for scientific research and study. Old because it isas old asmedicine itself, and new because ofthe lack of researchstudiesthathavebeencarriedout.Nowhereelsein medicine can the natural his tory of disease be observed and recorded over many yearsby patient documentation by practising physician naturalists.Nowhereelsemaytheinterpersonalandintrafamily factorsbestudiedasthey influencethe onset and patterns of symp-toms,problems and diseasecomplexes.Nowhere elsemay the early effectsof theinfluencesof environmentalhazardsbeappreciated providing that we are on the lookout forthem. Nowhere else can the physiciantrainandeducatehirnbetterthanbykeepinghisown personal simple clinical and operational recordsthat hecan review and analyse regularly the patterns ofthe diseases that he is managing andthe people forwhomheiscaring. Furtherreading Fry,j.(ed.)(1977).TrendsinGeneralPractice(London:RoyalCollegeofGeneral Practitioners) Hicks,D.(1976).PrimaryHealthGare,AReview(London:HMSO) 26 3 What isPrimary Care? Content andImplications Examinationofthecontentofprimarycarewillprovidesome appreciation of what it does today and what it might be expected to do tomorrow. In most countries the evolution ofhealth care services has created similar patterns of care in hospitalsand specialist practice and also at the level of primary care. The emphasis everywhere, until recen tly, hasbeenoncureandcareof establishedovertdiseasesandlittle planningandco-ordinatedactionhavegoneintopreventionof diseaseandpromotion of health.What hasbeendonehasbeenon anadhocbasiswithfewtrialsandexperimentstotesthypotheses, methods,techniquesandtheirresults,effectsandbenefits. Ifthe roles and efforts ofhealth care in general and primary care in particular are tobe different in the futurethen careful examination of thepresent content of workand itsmethodand technique hasto becarried out critically and constructively. FACTORSTHATAFFECTTHECONTENTOF PRIMARYCARE It hastoberealizedthat whilstthegeneralnatureandcontentof primarycarearesimilar,eachpracticeorunitprovidingprimary care isdifferent inso medetail. Therewillbedifferencesinfluencedbylocalepidemiologyand morbidity. Thus geography, economics and climatic conditions will createdifferingemphasisonthetypesandfrequencyof conditions and problems encountered. Tropical and developing rural areas will ANEWAPPROACHTOMEDICI:'-lE provideadifferent spectrum of morbidity and problems fromthose inadevelopedtemporateurban area. Therewillbedifferencesincontentinfluencedbycustoms, traditionsandexpectationsof thepublicandtheprofession.Thus in some systems and places primary care physicians will be expected andencouragedtoundertakecareof patientsinhospitalsaswell asinthecommunity.Insomesystemstheirnormalworkwill includesurgical,obstetricandgynaecologicalprocedures,whereas inothersystemssuchproceduresarenotcustomary,expectedor allowed. The content of primary care isvery much under the control of the patternofthenationalhealthsystemandonthecontrolsand directivesimposedonthehealthprofessions.I tdependsonthe resourcesandfacilitiesavailableandaboveallonthemethodsof paymentandremuneration.Inacapitationorsalariedsystemof remunerationthe incentives and inducements forprovision of extra servicesareverydifferentfromafee-for-servicesystem. Thecontentwilldependalsoverymuchonwhatthephysician seesashisrolesand what heisprepared toundertake and develop, particularlyinundevelopedareassuchaspreventivecareandfor specialprovisions forvulnerable at-riskgroups. PRIMARYCARE:SPECIALFEATURES Toremindourselvesitisnecessarytorecallthelevelsof careand administration(FigureI'3,page13).The level of primary care and firstcontactcareissi tedinalocalityoramicro-district.Inade-velopedcountrytherewillbeoneprimaryphysiciantoapproxi-mately2500persons.Thisfeatureisresponsibleforthecontentof primarycare.Itmeansthatthecontentof diseasewillbethose conditionsandproblemsthat canbeexpectedtooccurinapopu-lation base,or denominator, of 2500 persons.It isobviousthen that therewillbeapredominanceof themorecommonconditionsand an infrequency of themorerareconditions. Of practicalimportanccwillbedecisionsonwhichof thecon-ditionsof primarycareareamenabletocare,eureorprevention and which can be properly undertaken by those working in primary care. WHATISPRIMARYCARE?CONTENTANDIMPLICATIONS ANNUALVITALSTATISTICS An insight into the dimension of primary care are the vital statistics that canbeexpected in amicro-district community of 2500(Table 3. I).Thisshowstheapproximatenumbersof marriages,divorces, births and deaths that may be expected to occur in atypical year in a typical western developed community. The primary care physician willbecome involved inthe joys of thebirthsand marriagesand in thesorrowsandgriefsof thedivorcesanddeaths. Table 3.1Annualvitalstatisticsina priInarycarepopulationbaseof2500 persons (from Fry,1974) Vitalstatistics Numberoccurring per year per2500 Marriages 17 Divorces 5 Births 30 Primipara 13 Infant mortality Caesarean seetion Forceps deliveries 5 U nmarriedmother 3 Deaths 25 Cardio-vascular10 Cancers 5 Strokes 4 Accident Other 5 Children(Under15) 550 Elderly(Over 65) 375 (Over75)100 Thissetof annualhappeningsisacompositeoneandappliesto adevelopedwesternsociety.Similarnumberscanbedevisedfor adevelopingsocietywheretherewillbemorebirths,moredeaths, and higher infant mortality. SEVERITYOFDISEASE Diseases can be graded as 'acute major' or potentially life threatening acute situations,as'chronic'long-termconditionswithsomefunc-tional disability and 'minor' usually transient, self-limiting and with ANEWAPPROACHTOMEDICINE no risk to life or permanent disability.In primary care it is found that at any time approximately 65 % of conditions treated by a physician willbe minor,15% willbe acute major and 20%chronic. Theseproportionsarethoseexperiencedinatypicalfamily practice in Western Europe, N orth America, Australia, N ew Zealand or-SouthAfrica.Inadevelopingsocietytherewillbeasmaller proportionofchronicconditionsandmoreacutemajordiseases affecting children. CLiNICALANDSOCIALCONTENT There have been many studies carried out to measure and define the contentof diagnosesinprimarycare.Whattheyshowisavery similarpatternindevelopedcountriesinEurope,NorthAmerica and Australasia with somedifferencestobenoted.Table 3.2shows what a primary care physician who functions as a general practitioner inBritainandafamilyphysicianinEurope,NorthAmerica, Australia and N ewZealand, who care fora population of 2500may expecttomanage in atypicalyear. Table 3.2 demonstrates some very important facts.It shows clearly and dramatically what are thecommon and uncommonconditions of primary care.Of particular importance are the sm allnumbers of thespecialisthospitaldiseasesandthehugenumbersof thenon-hospital disorders. Table 3.2Annual prevalence of illness and other events in the experienceof aprimary physician caring forapopulation of 2500inadevelopedsociety(fromFry,1977;Hicks,1976; Marsland, Wood and Mayo, 1976) Condition Minor illness General Upper respiratory infections Skin disorders Emotional disorders Gastro-intestinal disorders Specific Acute tonsillitis Lacerations Eczema-dermati tis Persons per year 600 325 300 200 100 100 100 WHATISPRIMARYCARE?CONTENTANDIMPLICATIONS Table 3.2 - continued Condition illness - continued Acute otitismedia Sprains and strains Ear wax Acute urinary infections 'Acuteback' syndrome Menstrual disorders Vaginal discharge Migraine Warts Hay fever Hernia Piles Vertigo Chronie illness Chronic rheumatism Rheumatoid arthritis Osteoarthritis of hips Highbloodpressure Chronicmental illness Coronary artery disease(alltypes) Obesity Chronic bronchitis Anaemia Iron defiriency Pernicioll' -! 5 c

!. ! 4 .. c 0 j 3 ::l

eS 2 WHOCOMESANDWHY?SELF-CAREANDPRIMARYCARE I'" / / ./ I / )1/ /.r/// / //'-'--// ._-----. o10 -M IC--F 20 Figure 4.4 3040 AGE 5060 Consulting ratesby sexes. 7080+ Personconsultingrates Fromalargenumberof surveysquotedbyHicks(1976)there isapatternintheproportionof annualpersonconsultingrates Table 4.4Frequencyofannual consultations (from Hicks, 1976) Annual consultingrates Noconsultations 1consultation 2consultations 3 consultations 4 consultations 5--9consultations 10-19 consultations 20 and over 43 Per cent 34 16 13 9 6 14 6 2 ANEWAPPROACHTOMEDICINE (Table 4.4.).One-third of thepopulation at riskwillnot consultat all in ayear,another half willconsult lessthan three timesand less andlessthanoneintenwillconsultmorethententimes. Regional In the two national morbidity surveys quoted by Hicks(1976)there weredifferencesintheconsultingratesrecordedbygeneralprac-titionersintheregionsof EnglandandWalesfromalowof three consultationsperpersonperyearintheSouth-eastandWest Midlandstoahighof overfourinWales.However,therewasno regular patternbecauseneighbouringpracticesinthesameregion had consulting ratesthat differedby two-fold.It isquite likely that differentratesof patientconsultationsrepresentpatternsof phys-ician-behaviour and control more than medical and social needs. Socialclassandoccupation No great social dass differences in consulting rates were noted in the UK surveys.The rates were lower in socialdassesland 11than in IVandV,withthehighestratesinsocialdass111(OPCSand RCGP,1973). Theoccupationthathadby farthehighestconsultingratewas mining.Miners(and their wivesand children)had consulting rates that were twice the overall mean and three times as high as the lowest consulting occupation, agricultural workers. Thereasonsforthehighratesinminingwerenotthatminers suffered more injuries but rather because they required certification fromtheirphysiciansforsicknessabsence,andthehighrateswere accountedforbyminorillnesseswhichwereusedasareasonfor medically certificated leaveby the miners. WHODOESNOTCONSULT?THENON-ATTENDERS Each year'about one-third ofpopulations in developed societies with healthcaresystemsdonotconsulttheirprimaryphysicians.This proportion hasbeen foundinthe British NHS by Kohn and White (1976)intheirinternationalstudyandbyreportsfromNorth America and Australasia.In my ownpractice Ihave foundfurther 44 WHOCOMESANDWHY?SELF-CAREANDPRIMARYCARE thatro%of my population at riskwillnot consult meover 5 years andthatI % willnotconsultmeoverIOyears. Who are these non-attenders and how do they differ from the more regularattenders?KesselandShepherd(I964),Baker(I976)and Andersonetal.(I 977)havestudiedsomeof thefeaturesof non-attendersand Ihavedonethe same in my practice.Non-attenders aremorehealthythanthosewhoconsulttheirphysician,butthis applies only to major illnesses. They do not suffer any less from minor ailmentssuchascolds,coughs,accidentsandgastro-intestinalup-sets.Theyaremoreself-reliantandself-sufficientandapplymore self-treatment and self-medication than attenders.They have fewer expectations of the potential of the medical profession and of modern medicine.They are more likely tobe men than women. FREQUENTATTENDERS:THE'FAMIUARFACES' Almostone-quarter of thepopulationconsultmorethan fivetimes a year in the NHS(the mean rate isthree). Who arethese'familiar faces'? A few have conditions that do require frequent attention such asthosewhoare seriously ill fromacute conditions,therearethose whoareterminally illandthosewithchronicconditionsrequiring regular and frequent supervision. Ihave foundthat in my own practice the majority ofthe 'familiar faces'donotcomeunderanyofthesecategories.Mostofmy 'familiarfaces'arepersonsorfamilieswhoaremorevulnerable sociallyandjormedicallythantherestof thepopulation.They attendmorefrequentlyforminorailments.Theyaremuchmore pronetosuffer fromemotional andpsychosomaticdisorders.They seekmoreout-of-hourscalls.They havemorepersonalandfamily problems and crises.They are more likely tobe on long-term medi-cation with psychotropic drugs. Thesepersonsalthoughaminority,probablynomorethan 10-15% ofthe population,require proportionately,more care and support.U suallytheirpersonalproblemsareeither non-solubleor willimproveontheir owngiventime.Attemptsat radicalcure by the physician may cause more harm than good.This does not mean thatsympatheticlisteningandpsychotherapeuticsupportarenot required,rat her that the limits of care and curemustbeaccepted. 45 ANEWAPPROACHTOMEDICINE FUTUREOPPORTUNITIES Theprimarycarephysicianandhisteamareinakeypositionto control the use of services. They can prevent over-use and misuse by control and education,but even more important they should accept theopportunitiestoextendtheircare,involvementandinterests intothe community.Many of thereasonsforseekingmedical care areassociatedwithsocialandmedicalsituationsthatmaybepre-ventable, providing that they are discovered and medical and social measuresusedtoremedy them. References Anderson,J. A.D., Buck, C., Donaher, K. and Fry,J.([977).]. R.GaU.Gen.Pract., 27.[55 Baker,C.D.([976).]. R.Golt.Gen.Pract.,26,404 Dunnell,K.andCartwright,A.([972).MedicineTakers,PrescribersandHoarders (London:Routledge andKegan Paul) Elliott-Binns,C.P.([973). ]. R.GoU.Gen.Pract.,23,255 Fry,J.([974).GommonDiseases(Lancaster:MTP PressLimited) Fry,J.(ed.)([977).TrendsinGeneralPractice(London:RoyalCollegeofGeneral Practitioners) Hicks,D.([976).PrimaryMedicalGare:A Review(London:HMSO) Horder, J.P.andHorder,E.(1954)Practitioner,173,[77 Jefferys, M., Brotherston,J. H. F. and Cartwright, A.('[960). Br.]. Pm. Soc.Med., 14,64 Kessel,W.I. N.and Shepherd,M.(1965).MedicalGare,3,6 Kohn,R.and White,K.L.(1976).HealthGare(New Yorkand London:Oxford U niversity Press) Logan,W.P.D.andBrooke,E.([957).Surveyof Sickness,1943-1952(London: HMSO) Morrell,D.C.and Wale,C.T.(1976).].R.Galt.Gen.Pract.,26,398 Office ofPopulation Censuses and Surveys(OPCS)and RoyalCollege ofGeneral Practitioners(RCGP)(1973).MedicalStatisticslromGeneralPractice:Second NationalMorbiditySurvey,1970-1971(London:HMSO) Thacker, S.B.,Gm'ne, S.B.and Scilljen, E.J. (1977).Int.]. Epidemiol.,6,55 Wadsworth,M.E. J., Butterfield,W. J. H.and Blaney,R.(197[).HealthorSickness: TheGhoice01Treatment(London:TavistockPublications) White,K.L.,Williams,T.F.andGreenberg,B.G.(196[).N.Engl.]. Med., 265,885 Further reading Kessel,W.I. N.([963).M.D.Thesison Non-aUenders(Cambridge University) Mechanic, D.(1962).]. GhronicDis.,15,189 WHOCOMESANDWHY?SELF-CAREANDPRIMARYCARE Parsons,T.(1951).TheSocialSystem(Chicago:FreePress) Robinson,D.(1971).TheProcess01 BecomingIII(London:RoutledgeandKegan Paul) Stirnson,G.andWebb,B.(1975).GoingtoseetheDoctor(London:Routledgeand Kegan Paul) 47 5 Work:Quantity andQuality-Manpower Policies WORK:WHAT15IT? The volume and quality ofwork in primary care mustberelated to thenatureof primarycareitself-discussedanddescribedinthe preceding chapters.Consideration ofhow much work isbeing done, should be done and needs tobe done, and how it might be done,are aIlimportant issuesif soundplansandforecastsaretobemade for our future organization of primary care,and health care in general. Primary care isaspecialand essential levelof health care.Itschief featuresareeasy anddirectaccessandavailability forfirstcontact andlong-termcontinuingcareforarelativelysmallandstatic populationbaseof 2000-3000personsinadevelopedsociety.The situation isvery differentindevelopingcountries. The implicationsof thesefeaturesarethat thecontent of clinical morbidity,medico-socialpathology and familyandpersonalprob-lemswillbeheavily weightedtowardsthe more common and more minorconditionsandsituations,withasizeableproportionof chronic conditions requiring long-term care and support. Most ofthe persons seen by primary physicians in such circumstances will be weIl known fromapersonalor familybackgroundandpastexperiences of care over many years.Very fewwillbenew patients.In my own practice lessthanro% ofthe patients who consult me are new. NATUREOFWORK The chief component of the work of any clinician caring forpatients mustbethedirectpersonalandprivateface-to-faceconsultation. 49 ANEWAPPROACHTaMEDICINE Thismaytakeplaceinthephysician'soffice,orclinic,oritmay takeplaceinthepatient'shorne,orinahospitalorsameother institution.The private consultation isessential tobuild up doctor-patientrelationshipsandmutualunderstandingandrespect.It is the situation where the patient must be allowed, and encouraged, to giveahistoryof hisillnessorproblem.Itistheplacewherethe physiciancan carry out anexaminationandmakeadiagnosis. Themostimportantcomponentof anydiagnosticassessmentis thehistoryasgivenbythepatient,andfurtherextractedbythe physician.Aphysicalexamination,local or general,isasecondary processcarriedoutbythephysicianbutitslimitationsmustbe recognized.Anexamination of the patient isby nomeansusualor necessary for every consultation in primary care. Many of the minor conditionsseenneed,atmost,abrief localexamination.Manyof the consultations in primary care (about two-thirds to three-quarters of allconsultations in my own practice)are follow-upconsultations forpatients und er continuing care. Criticalself-assessmentisnecessaryof our ownclinicalhabitsif wearetoavoidrepetitiveroutineandstereotypedclinicalhabits that have been learned in the untypical situations of undergraduate teaching hospitals and which are scarcely applicable tothe require-mentsof andconditionsinprimarycare.Wemustaskconstantly the question ofwhat forwhat? That is,what are wedoing, far what reasons,towhat purpose andtowhat outcome?New methodsand techniqueshavetobelearnedand relearned. The samereasoningappliestothenextpart of theconsultation, theinvestigations.Oneof thecharacteristicsof theclinicallylazy and tired mi nd isto request a whole range of,or a battery, ofroutine investigations, often for no specific purpose but in the vain, and often fodornhopethatsomethingmayturnupfrompathologicaland radiologie alscreeningprocesses.Althoughithasbecomeapart of modernmedicalpractice,theextensiveuseof investigationsisnot acriterion of good clinical care.Byallmeans let ususethebenefits of themodernlaboratoryandotherinvestigativedepartmentsto help confirm clinical diagnosisand toassessprogress,but clinicians must be masters of the machines and not their servants.In my own practice in lessthan one consultation in ten do Irefer my patient for pathological or radiologie al investigations. Adiagnosisistheoutcomeof theconsultationandthismustbe WORK:QUANTITYANDQUALITY-MANPOWERPOLIeIES followedbyaplanof management or treatment.Thestepsinthe consultative processhavetobe followedin primary clinicalcare as elsewherebutwiththeconditionsandsituationsencounteredthe process doesnot oftenrequiretobe lengthy or elaborate. This does notmeanthat themethodsof primary ca reareinferiortothoseof hospitalspecialistpractice,ratherthattheyhavetobeadaptedto needs and requirements. The indirect consultation is another form of work in primary care. Itcomplementsthedirectface-to-faceconsultation.Itmaybe atelephoneconsultation,morecommonandpopularinNorth AmericanthaninEuropeanpractice.Itmaybethroughcorre-spondence or it may be the repeat prescription for the unseen patient (seealsoChapter8).Thelatterhasbecomeamajorfeatureof British general practice. Work in hospitalmay be asizeable part ofprimary care,but the extent depends onIoeal facilitiesand customs.It isvery much part of primary care in N orth America, Australia and in many developing countriesbut it isnoteustomaryinWesternEurope,Scandinavia or the socialist countries. Administration, of necessity,occupies some time in primary care, but it needbe asmallpart.Aregular commitment hastobegiven toactiveparticipationinprofessionalactivitiesandcontinuing education. WHATFORWHAT? Ihave suggestedthat the basic contents of primary care are similar in allsystems:sotheyare.What isdifferent arethedifferingways in which physicians tacklethem. Fewcomparativestudieshavebeenundertaken,butoneisof particular interest.Marsh,Wallaceand Whewell(1976)examined the processof consultationby25physicians inIowa,USA,and by 28physiciansinNorth-eastEngland.Theconditionsseenwere similarbutcleardifferencesof managementwerenoted.InIowa the physicians undertook more examination, more use of procedures andinstrumentsandrequestedmoreinvestigations.Manymore were weIl-patient routine examinations carried out by the American physicians.The Britishgeneralpractitionersweremoreconcerned with the whole patient and placed more emphasis on emotional and 51 ANEWAPPROACHTOMEDICINE so ci al aspects.There was more use of the prac ti ce team in care. The authorsconcludedthat'Americandoctorsaremoreorientated towardsaritualisticclinicalapproachleaningheavilyoninvesti-gationandhospitalsupport.Theirsystemmustbeexpensive. English doctors seem to operate at a less definitive level of diagnosis. ' What thestudy didnotmeasure wastheoutcomeof careinthe twosystems.In spiteof thedifferencesinemphasisit isverylikely that thereare few,if any,differencesinthe recoveryrates or other outcomesinmeasurementsinthetwopatternsof primarycare. More critical evaluative studies need to be carried out to assess 'what forwhat?'. We needtodetermine wh ether ritualistic clinicalprocedures are usefulandif soforwhatandinwhatcircumstances?Weneedto know whether weH-patient screening and batteries of investigations shouldbeextendedbecausethey areusefulin health promotion or becausetheyareusefulin increasingthephysician'sincome. INFLUENCINGFACTORS There are a number of factorsthat are involved coHectively in work patterns. IVolumeof work that presentsThis depends on the population cared for,on the extent ofmorbidity and medical and social needs and on demands and expectations. 2Methodsandtechniquesof carethatareusedAretheythemost appropriate,effectiveand efficient? 3TimeavailableHowmuchtimearethephysiciansandothers providing carepreparedtodevotetotheir work? 4ResourcesavailableWh atmanpowerisavailable,medicaland nursing,andwhatsupportaretheygivenbyhospitalandso ci al services? 5Outcomeand qualityof careThesearetheultimatesand the other factorsmustblendtoac hievesatisfactory outcomes. DATAONWORKPATTERNSINPRIMARYCARE Therehasbeenmoredata publishedon workpatternsinprimary careandofindividualpractitionersthanofphysiciansinother WORK:QUANTITYANDQUALITY-MANPOWERPOLICIES medicalfields.Referencewillbemadetopublicationsfrommany countriesandaconstantpattern emerges.However,incomparing datacollectedinthevariouscountriesthereareproblemsof defi-nition and recording. There are also differences of detail in the work of primary physicians in different health systems that are influenced by administration,organizationandremuneration.Providingthat basic data are recorded, comparisons are possible. Thus it ispossible tomakecomparisonsonthebasisof consultations(volumebyday andweek;placeof consultation),hospitalwork,indirectconsul-tations(phonecalls;repeatprescriptions;others),out-of-hours work,administrativetasks,andtimespentonduties. PUBLISHEDREPORTS There follow summaries ofsome re ports on work patterns in primary care.Theseservetocreateafactualbase. Europe,North AmericaandSouth America HealthGare(KohnandWhite,1976)isapublicationof aWorld Health Organization team that collected data from three continents, Europe,North AmericaandSouth America,fromsevencountries and fromtwelve areas.It isbased on interviews with 48000 persons. For a population base of 2500 persons there was a weekly volume of work with a primary physician of 2 10 contacts.The range was from a high of 300 in Buenos Airesto a low of 150 in Helsinki.One of the factors in this two-fold difference was the equivalent weekly contact-rateforotherhealthpersonnel,suchasnursesandsocialworkers whichwas200inHelsinkiand105inBuenosAires,thusalmost levelling upthe totals of thetwo setsof contacts(i.e.405 in Buenos Airesand350 in Helsinki). Intheyearof thesurvey70%of thepopulationsstudiedhad consultedaphysician.Of thedoctor-patient-contacts89%were face-to-faceconsultations.Furtheranalysisof thecontactsshowed tha t : 65% were in the doctor' s office; 5 % were in the patien t' s horne; 18% were in a hospital or other dinic;10% were on the telephone; 2%were elsewhere. 53 ANEWAPPROACHTOMEDICINE USA TheArnericanMedicalAssociationpublishesaProfileof Medical Practice(AMA,1976).Thisincludesdataontheworkpatternsof variousspecialtiesandgeneralpracticeintheUSAfrornsampie analyses.The Arnericangeneral practitioner in1974 averaged190 patient-contactsinaweekinwhichheworkedfor5 Ihours. Geographicallytherewasarangefrorn273patient-contactsper weekintheEastSouthCentralregionto139inthernid-Atlantic region.Ofthe weekly rnean of 190 patient-contacts,151were in the physician'soffice,34wereinhospitalandonlyfivewereinthe patient's horne. Riley(1969),inNewYork,reportedaweeklydoctor-patient-contact rate of 18 I, and Baker et al.(1967), in rural Missouri, found a weekly doctor-patient contact rate of 198. USSR In rny book MedicineinThreeSocieties(Fry,1969)Iquote that in the USSR the prirnary physician isexpected to carry out approxirnately 130 patient contacts(consultations)in a week ofwhich one-quarter willbe inthepatient's horne. UK In Britain,TrendsinGeneral Practice(Fry,1977),the average weekly volurne offace-to-face consultations is175(160in the officeand15 inthepatients'hornes)plusanother50ormoreindirectconsul-tations. Canada InTheFamilyDoctorWolfeand Badgley(1972)report on thework ofaprirnarycaregroupinSaskatoon,Canada.Thephysician carriedout35patientcontactseachdayorabout190inaweek. Of theseI15wereintheoffice,30inhospital,10hornevisitsand 35 on the telephone. Australia FrornAustraliaonGeneralPracticeinVictoriaScottonandGrounds (1969)reportthatthegeneralpractitionersaveraged186doctor-patient contactsinaweekof which28werehornevisits. 54 WORK:QUANTITYANDQUALITY-MANPOWERPOLICIES New Zealand From N ewZealand onTheContent01 GeneralPractice,Lough(1967) reportsahigherworkpatternof 209doctor-patientcontactsper weekof which67werehornevisits. APROFILEOFAWEEK'SWORKOFAPRIMARY PHYSICIAN These reports also quoted the time spent by physicians in their work. Table 5. Iisarepresentation of the collected and collated data from these sources. There isa remarkable similarity in the volume of work as measured by doctor-patient contacts in primary care in developed countries.Thesecontactsmaybedirectface-to-faceconsultations, at the office, patient's horne or hospital, or they may be indirect (such astelephone)contacts. Table 5.1Aprofileof theworkof aprimarycarephysician (from the sources quoted in the text) Doctor-patientcontacts lv!inutesNumberHours percontac!perweekperweek Office(consulting roorn)10 14024 Horne visits 30 10 5 Hospital work 15 20 5 Phone 15 2 Other indirectconsultationsIO Out-of-hours calls 53 Total200 40 The amount of time spent oneach of these isvariable.InBritain themeantime foran officeconsultation isabout 7 minutes, in New Zealand and Australia it is15minutes and in USA it is20minutes. Forhornevisitsthetimewilldependondistancestravelled,but 15-30minutesisthequotedaverage.For hospitalworkitdepends whetherthephysicianiscarryingoutalengthyprocedureor afollow-upround,but10-15minutesperpatientisagenerous average.The200contactsrepresenta40-hourweek,butthereis arangefromover60hoursq uotedinN ewZealandtolessthan 30hoursin someBritishpractices. To this profile of work have to be added possible extra professional tasksincluding:postgraduateexercises,suchasclinicalmeetings, 55 ANEWAPPROACHTOMEDICINE seminars,lecture-discussions;committeeandadministrativework; teaching and research.Our typical primary physician may therefore beworkinga45-50-hour week. TEMPORALTRENDS Workpatternsinprimarycarearenotstatic.InBritainthereare dataonthetrendsof consultation(doctor-patientcontacts)rates extending back sometimes over 30years.These have been collected inthe RoyalCollege of General Practitioners'publicationTrendsin General Practice(Fry,1977). There are data from twelve practices that have kept regular and continuing records and there isthe data from twonationalmorbiditysurveyscarriedoutduring1955-6and 1970-1 involving around one hundred practitioners in each survey. Theseshowafallinconsultingrates.Hornevisitingrateshave decreasedby60%and officeconsultingratesby20%. Ihave kept records of all face-to-face consultations in my practice since1947- Myworkasmeasuredbyconsultationsperperson (patient)per year hashalved during thisperiod(Figure5.1).Most of thereductionswereinhornevisiting,butappreciablefallsalso occurred in officeconsultations. 4 1.0 3 > 0.75 J: 0 3 '" < in' a' 'C 0.5

'C '"l 0 ::J

-< '"2: 0.25 Hornevisits Officeconsultations

195019601975 Figure 5.1Trendsinworkpatternsinageneralpracticefrom1947to1976. WORK:QUANTITYANDQUALITY-MANPOWERPOLICIES Consulting rates are measured astotal numbers of annual consul-tationsdividedbythepopulationatrisk.Suchannualconsulting rates per person are more accurate representations ofwork patterns than simplestatements of numbersof consultations.Suchratesare difficulttocalculatewhenthepopulationatriskisunknownor uncertain.It isonlypossibleinasystemsuchastheBritishNHS wherepatientsregisterwithageneralpractitionerandheispaid capitationfeesonlyforthosewhoareregisteredwithhirn.Itis importantthereforethatthenumbersareasaccurateaspossible. It isprobable that the mean annual person-consulting rate in the NHS isaround fourconsultationsper personper year.Thisme ans that, ifin a practice with 2500 registered patients (ofwhom 65-70% will consult hirn in a year)a general practitioner has10000 face-to-faceconsultationsinayear,therewillbeaperson-consultingrate of IO 000/2500 or four consultations per person per year.Such rates of work or services related topopulation are important also in plan-ning forfuturemanpower andresourceneeds(videirifra). Althoughthemeanannualperson-consultingrateisfour,there arepublishedratesrangingfromlessthantwotomorethansix. Suchathree-folcldifferencedemandsexplanation.Sofarthe differences cannot be explained by local medical or social morbidity or most other external factors.They appear tobe influenced largely byinternalfeaturesof thepracticesandtheirphysicians.Inthe SecondNationalMorbidity Survey(OpeS,1974)amongthe par-ticipating practices there were so me neighbouring practiees from the same area with the same loeal conditions where the eonsulting rates differed by 2-3 fold. Two eontrary trendsinBritain,suggesting inereasing workloads ingeneralpracticehavebeenthepreseribingratesbygeneral practitioners and market research surveysforpharmaceutical co m-panies.MedicationcanbeobtainedundertheNHSwithapre-scriptionsignedbyageneralpractitioner.TheDepartmentof HealthandSocialSecurityinitsannualreportsgivesthean nu al prescriptionrateperperson.Thatisthenumbersof prescriptions issueddividedbythepopulation.Thishasshown an increase from fiveannualprescriptionsintheI950Stooversixprescriptionsin 1975.Sincetheannualface-to-faceconsultingrateisfour,apre-scribing rate of sixmust mean that at least two of the preseriptions wereforunseenorindireeteonsultationsandthatithasbeenan 57 A:"lEWAPPROACHTOMEDICI:"IE increase intheindirect prescriptionsthat hasresultedintherisein prescribing rates and not any increase in face-to-faceconsultations. IntercontinentalMedicalStatistics(IMS)isamarketresearch companythatcollectsinformationongeneralpractitionerpre-scribing habits by inviting sampies of practitionerstokeepprospec-tiverecordsof oneweek'swork(IMS,1977).Amongtheitems recordedareconsultations.IMSdatashowanincreaseindaily consultationsfrom32to38overthepastdecade.U nfortunately there isnoinformation on the definitions ofconsultations nor of the accuracy and validity of thedata. APRIMARYMEDICALMAN POWERMODEL If we can accept that 10000 face-to-face consultations isa reasonable volume of work foraprimary physician then wecan begintomake man power forecastsforthe future.This impliesaweeklyvolume of 200 consultations and a daily volume of 40 consultations for a weekly basictimeexpenditure of 40 hours or 8 hours a day. Acceptingthe10000 annualconsultationsasafixedtargetthen thefuturemanpowerrequirementsofprimaryphysicianswill dependontheannual personconsulting rates.Table 5.2showsthe sizesof populationsthataprimaryphysiciancouldcarefor,with afixedannualtotalnumberof IO 000consultations.I tshowsalso thenumbersofprimaryphysiciansthatwouldberequiredfor apopulation of 50millionpersons.Thus,withaconsultingrate of twoconsultationsperyeartheprimaryphysiciancouldcarefor 5000persons,withaconsultingrateof threefor3333,withacon-sulting rate offour for2500 and with a consulting rate offive for2000 andwitharateof sixfor1667persons. Forapopulationof 50millionandaconsultingrateof twoa healthcaresystemwillneedIO 000primaryphysiciansandfor aconsulting rate of six,30000 physicians.It nowrequiresacapital expenditureof {,Imillion($2million)totrain,pay,supportand pensioneachprimary physicianintheBritishNHSandthediffer-ence of {,20000 million($40000 million)between the costsofthese twonumbersof physiciansisahuge sumthat hastobeconsidered most carefully. Someprimaryphysiciansareabletoprovideapparentlygood care working at a rate of two an nu al person-consultations and others WORK:QUANTITYANDQUALITY-MANPOWERPOLICIES work at a rate ofsix providing care with similar outcome. In planning theintendedworkratesmustbetakenintoaccount. Table 5.2Modelof patientsperprilnaryphysicianfortotal annual consultations of 10000 Consultingrates Patients per physicianNumbersof primary per person per year fortotal annualphysicians fora consultationsof 10 000populationof 50 million X2 5000 10000 x3 3333 15 000 x4250020000 x5 2000 25 000 x6 166730000 QUAUTY Quality of care isas elusive as amirage and more so in primary care than in other medical fields.Major problems are those of definition andmeasurement,buttherealsoistheproblemof whodoesthe measuringandassessing.Shouldwebemore interestedinthe sub-jectivesatisfactionsof consumersonthewaysinwhichtheyare cared forand treated, or should weplace more reliance in planning ontheobjectivemeasurementsof thestructure,processandout-come of care asrecordedby medical economists and scientists? Further problems in primary care are that the nature of the con-ditionsissuchthatmanyarerelativelybenign,self-limitingand self-resolving,forwhichtheendpointsof activetreatmentmaybe indistinguishable fromthose in whom notreatment hasbeen given. Nevertheless, in spite ofsuch problems attempts must be made to definequality,tomeasureit,tocreatemodelsof excellencetobe followed,and to provide incentives, facilities and resources by which highquality of caremaybeachieved. INFLUENCES Thevolumeandpatternsof workareinfluencedby. manyand various factors.These must be recognized,examined and changed, perhaps,if futuremethodsare tobe improved. 59 ANEWAPPROACHTOMEDICINE Customs andhabits Manyof thecustomsandhabitsof utilizingmedicalservicesare ingrainedintraditionsandbeliefs.Thesemaybefamilial,com-munal, regional or national. They may be based on cultural, religious or other beliefs.In Chapter 4,the variations in consulting patterns havebeennotedand there isurgent needtostudy and understand why patients utilize health services in the ways that they do and also toassesstherealbenefitsof the servicesprovided. Customsandhabitsaredevelopedandacquiredalsobythe medical profession and individual habits are built up by physicians. Everyphysicianhashis(orher)ownhabitsof diagnosis,investi-gationandtreatment.Theusefulnessornon-usefulnessof current medicalhabitsandcustomsmustbeevaluated.Manymaybenot only uselessbut potentiaHy dangerous and wasteful. Expectations Neverbeforehavepublicandprofessionalexpectationsof medical carebeengreater.Theynowexceedreality.Thetruescopeof medicine isstilllimited. One effect of positive health education and liberal medical information onthemedia hasbeen the building up of an over-expectant and over-demanding public.I t istimenowto developamorehonestformof negativehealtheducationof the publicandtopointoutthelimitationsofwhatmedicineand physicianscanachieveandtoconcentratemoreontheresponsi-bilities ofthe individual in his own health maintenance and self-care. Money incentives Inmanyhealthsystemsmedicalcareisstillabusinessandthe physiciansareconcernedin sellingtheirskillsand services.Thisis notablewherefees-for-servicesarethemethodsof remuneration. Thus,themoreservicesthat areprovidedandthemoreexpensive they are,thegreater willbethephysician'sincome.Thisdoesnot happen in systems where payment ofphysicians isby capitation fees or by salary,the physician's incomeremainsthe same whetherthe patient is sick or weH,and whatever the services provided. These fee-incentives may be one explanation for the disproportion-atepopularityof weH-patientcareintheUSAandCanada,with frequentcheck-ups,screeningandtests.It maybeanexplanation 60 WORK:QUANTITYANDQUALITY-MANPOWERPOLIeIES fortheratesof surgicaloperations-such ashysterectomy,circum-cision,tonsillectomy, cholecystectomy and appendicectomy-which arethree-foldhigh erinNorthAmericathaninBritain(Bunker, Barnes and Mosteller,1972). Morbidity andpoverty EveninwelfaresocietiessuchasBritainandSwedenthereare regionaldifferencesinmorbidityandmortalityratesandinthe extent of social pathologies between the different social dasses.Such differencesinftuenceworkdemandsandneedslessthanexpeeted. IntheBritishMorbiditySurveystherewerenogoodcorrelations betweenlowsocialdassareasandhighworkr'ates(OpeS,1974). Practice organization Amajorinftueneeonworkvolumehasbeentheevolutionof the primarycareteamwhereworkcanbesharedbetweenphysieian, horne nurse, pu blic health nurse, social worker and medieal secretary. The solo single-handed do-it-allhirnself physieian now isan anaeh-ronismandwasteshistrainingandhistalents.Muchof theold tradition alphysieianworkcanbedelegatedto,andsharedwith, hisnursing and other colleagues. Disincentives Mentionhastobemade of theuseof disincentivesandbarriersto theuseof medical services.High fees,inaccessibleunits,long waits and delays,non-sympathetic care, and unsafe and unpleasant treat-mentmayallactasbarrierstothepublie. Education,motivations andeffectiveness of the physician Aprimaryphysieian whoisspeciallytrainedandeducatedforthe special field of primary care should use histime and resourees better than one who istrained asa would-bebut failedhospital speeialist, orspecialoid.Histrainingshouldhelphirntounderstandthe ehallenges,thenature,the diseases,themethods andtheproblems 0(' primary eare.He will be able touse his resources better and work wellwith hispara-medical colleagues. 61 ANEWAPPROACHTOMEDICINE If he isgivenalsothe simple and relatively in expensive resources neededthenhewillprovideeconomic,effectiveandefficientcare satisfying tohirnself and tohispatients. FUTUREIMPLICATIONS 'Work'isaflexiblemedicalcommodity.Aremarkablesimilarity exists among primary physicians in developed countries of an annual volume of 10 000 consultations, that isapproximately 200 per week, 40 per day with a mean weekly work time of 40 ho urs per physician. Yettherearelargedifferencesinfluencedbyhabitsof individual physicians.Whilst somephysicians,andIam one,canprovidefor 5000careof asoundandreasonablequalityandothersfindthat caring for1500 patients isastrain,then it isimperative that wetry todiscoverthe reasonsforthesedifferences. Providingthattheprimaryphysicianistrainedforhisspecial rolesand tasks;providing that he issufficiently curious to carry out continuingself-assessmentandsimpleresearchonhispracticeto test what isusefuland uselessin hiswork; providing that headopts simpletime-savingandeffectivemethodsof care;providingthat he is supported by a collaborative and well-trained team ofnursing, socialworkand secretarialcolleagueswithwhomhecan sharehis work;providingthathehasreadyaccesstodiagnosticandthera-peutic facilities;providing that he isencouraged by suitable incen-tives and leadership to achieve good quality care and avoid waste of resourcesandtime;andprovidingthathehasgoodrelationsand mutualunderstandingwithhispatientsandwithhiscolleagues then,withtheseprovisos,Isee noreasonwhyweshouldnotbe aimingforoneprimaryphysicianto3000,4000oreven5000 patients. References AmericanMedicalAssociation(1976).Profileof MedicalPractice(Chicago:AMA) Bakcr,A.S.etal.(1976).Mo.Med.,64,213 Bunker,J.P.,Barnes, B.A.and Mosteller, F.(eds.)(1977).Gosts,Risks and Benefits of Surgery(New York:OxfordUniversity Press) Fry, J.(1969).MedicineinThreeSocieties(Lancaster:MTP PressLimited) Fry, J.(ed.)(1977).TrendsinGeneralPractice(London:RoyalCollegeof General Practitioners) IntercontinentalMedical Statistics(1977)'Personal communication. WORK:QUANTITYANDQUALITY -MANPOWERPOLIeIES Kohn,R.andWhite,K.L.(1976).HealthGare(NewYorkandLondon:Oxford University Press) Lough, J.D.(1967).N.Z.Med.J., 66,Supplement Marsh,G.N.,Wallace,R.B.andWhewell, J.(1976).Br.Med.J.,I,1321 Officeof PopulationCensusesandSurveys(1974)'StatisticsfromGeneralMedical Practice,SecondNationalMorbiditySurvey(London:HMSO) Riley,G.J.(1969).J.Am.Med.Assoe.,208,2307 Scotton,R.B.andGrounds,A.D.(1969)'Med.J. Aust.,SupplementNo.1 Wolfe,S.andBadgley,R.F.(1972).TheFamilyDoctor(NewYork:The Milbank MemorIal Fund) 6 TheNature andNatural History of CommonDiseases Anexpectantpublichasbeenencouragedbyanenthusiasticand optimisticprofessiontoexpect and demand acure foralmost every illandsymptom.Itbecomesdifficulttoresistthe'dosomething' demands ofthe 'gawd sakers'(for God's sake do something doctor!). Nevertheless it isessential that some re-education ofboth public and professioniscarried out asacounterweight, sothat wemay