BMJ  2005;330:547 (5 March), doi:10.1136/bmj.330.7490.547

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PERSONAL VIEWS

A US model for primary care in the NHS

In July 2001 I began a year working in a primary care trust in east London. My career had already taken me from Canada, where I trained, to the United States, where I worked for 20 years in a community health clinic. There we served a medically indigent population, including refugees and new immigrants of Asian, African, and Latin and South American origin. In going to England I was eager to return to a country with socialised medicine and to compare the NHS's ability to provide care for a community with a similar low socioeconomic profile. To this end I became the lead person for cardiovascular health promotion in Tower Hamlets for a year.

Our centre in San Diego, one of 10 000 non-profit, community based health centres across the country, provides care for adults and children, comprehensive family planning, gynaecological services (including colposcopy), mental health services, smoking cessation counselling, and health promotion. Funding comes from payments from patients, fee-for-service billing, managed care billing, and government grants. Care is provided in seven languages with the help of professional interpreters, who are also trained as medical assistants. In the pre-examination they document descriptions of any chief complaint, take vital signs, and anticipate physicians' needs by carrying out eye examinations, coordinating glucose measurements, and performing urinalysis and pregnancy tests.

The NHS could make simple and inexpensive changes to improve outcomes

The mission of the San Diego family care centre is to maximise its limited resources to provide high quality health care to a poor population. The centre uses treatment "pods" consisting of six fully equipped examination rooms with examination tables, ophthalmoscopes, otoscopes, wall mounted blood pressure cuffs, and all the supplies that healthcare practitioners might need to obtain routine specimens. The providers include physicians, nurse practitioners, and physician assistants. One treatment room in each pod includes an electrocardiograph, minor surgical equipment, respiratory treatment equipment, and a fully equipped crash cart for emergencies. A nurse is assigned to the central station of each pod and provides support, triage, and technical and dispensary services for all six examination rooms. An onsite clinical laboratory provides immediate results for services such as pregnancy tests, urinalysis, wet mounts, streptococcus screening, and glucose and haemoglobin determinations. The results from outsourced laboratory studies are reported to the centres by teleprinter, usually within 24 hours. Although the medical records are not computerised, laboratory results, pharmacy records, billing, scheduling, and case management are available to staff on line.

Several glaring differences became apparent after I talked to GPs in their practices and to NHS employees in east London. East London's primary care system was severely challenged by the physical premises where GPs practise. There was also a noticeable absence of any ancillary support staff, such as medical and laboratory assistants or nurse practitioners. I witnessed triaging out of basic services, including primary care complaints referred to specialists, which is understandable, given the lack of time and support reported by the GPs. The excellent computerised medical records system was not being used to monitor patients for the preventive services suggested by international groups such as the Cochrane Collaboration and the US Preventive Services Task Force. The auditing system was poorly coordinated with the primary care offices, making quality improvement difficult.

Using the model of the US community health clinic, the NHS could make simple and inexpensive changes to improve outcomes, without increased spending. GPs would be relieved of low level tasks that could be accomplished by medical assistants. Medical assistants (who in the United States undergo a six month certificate programme) could be trained to measure vital signs, thereby reducing the high rates of undetected hypertension in England, provide medical translation (thereby increasing the quality of the GP-patient interaction), and perform minor procedures like venepuncture and electrocardiography. Either medical assistants or minimally trained laboratory assistants could provide basic laboratory services. With the extra time available in the "nine minute visit," the GP practices could absorb the roles of some of the specialty care, but perhaps even more importantly they could provide more preventive care and health promotion. Nurse practitioners could help doctors with problems that lend themselves to clear protocols. Through auditing, standardised quality control and assurance, and specific NHS support of ancillary licensed and certified healthcare providers in general practices, the NHS could look towards long term cost benefits and extended quality of life.

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department of family and preventive medicine, University of California, San Diego lhillbaird{at}aol.com

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Rapid Responses:

Read all Rapid Responses

US and UK primary care

Tom Marshall
bmj.com, 4 Mar 2005 [Full text]

What can we learn from the US ?

L S Lewis
bmj.com, 5 Mar 2005 [Full text]

Why was this published now?

john sharvill
bmj.com, 8 Mar 2005 [Full text]

Primary Care Performance Comparison/A Questionable Task

Syrus Adl
bmj.com, 8 Mar 2005 [Full text]

What is the need?

pablo millares martin
bmj.com, 9 Mar 2005 [Full text]

An elegant solution: US Community Health Centers - and Physician Assistants

Margaret Allen
bmj.com, 12 Mar 2005 [Full text]

Author's Reponse: A US model for Primary Care in the NHS

Linda L Hill
bmj.com, 14 Mar 2005 [Full text]

Equity a problem everywhere

Avril Danczak
bmj.com, 17 Mar 2005 [Full text]

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