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OBSERVATIONS: Iona Heath A general practitioner for every person in the world BMJ 2008; 336: 861 [Full text]

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What is needed are more primary health care workers, not doctors

Peter C Arnold   (19 April 2008)

Money and Career

Graeme Mackenzie   (24 April 2008)

Primary Care is the front line in the battle for a healthy world.

Alexander SD Spiers   (26 April 2008)

What is needed are more primary health care workers, not doctors 19 April 2008
Peter C Arnold, Retired GP Sydney, Australia Send response to journal: Re: What is needed are more primary health care workers, not doctors	While supporting Iona Heath’s contention that every person needs a primary health carer, I am doubtful that every person in the world need a primary care doctor. Heath is concerned for primary care in the ‘poorer’ countries. Is this not better managed by training primary health care workers, comparable with Australia’s Aboriginal Health Workers, China’s ‘barefoot doctors’ and Russia’s ‘felshers’? Training primary carers to MBBCh level results in personnel knowledgeable about and often reliant on secondary and tertiary care, which is often just not available in the areas most in need of primary health carers. In addition, many, stimulated by their MBBCh studies, are not satisfied intellectually and become frustrated in dealing with the everyday problems of local communities where they lack these back-up resources(1). Many migrate to the richer countries, which, short of medical personnel, welcome them(2). I doubt that I am alone in thinking that the Alma Ata goals could more readily be achieved if the focus were on training many more primary health care workers(3). Training more doctors is likely to be self-defeating. (1) Ogbu UC. The Metrics of the Physician Brain Drain. NEJM 2006;354;5:528-9. (2)Buchan J. International recruitment of health professionals: We need to identify effective approaches to managing and moderating migration. BMJ 2005;330:210. (3) Omaswa, F. Human resources for global health: time for action is now. Lancet 2008;371:625-6. Competing interests: None declared
Money and Career 24 April 2008
Graeme Mackenzie, GP OUT OF HOURS North Cumbria Send response to journal: Re: Money and Career	This article and the rapid response has prompted me to put some thoughts down about the future of the primary care medical profession in the next few decades. I am an out of hours GP working with senior and highly trained nurses and with decades of experience of working with similar nurses in practices. The current debate is fuelled by the Darzi review and some articles developing hypotheses that we need fewer primary care doctors but more nurses, I wonder what will happen to the the role of "doctor" in years to come. Certainly nurses can do much of primary care if trained and instructed. Who does that training? Does the GP in the UK offer anything that cannot be broken down into specific nurse roles? Would primary care be more or less effective with a dominance of nurses? Will a dominance of nurses drive down medical salaries? If the policy is for more nurses, what will happen to the current medical workforce and that in training? Who will recompense the current medical workforce for the huge investment in getting a medical degree and post graduate qualifications if there are no jobs or much reduced salaries? Is it not OK to choose a career because it has good remuneration? Will anyone bother to choose medicine as a career when they see any well developed part of health care being hived off to armies of nurses? Is that good or bad? Is it a betrayal of the profession who have worked hard to develop practices and services to then undermine the role of doctor? And so it goes on. Perhaps we will only find out what doctors do and how effectively by getting rid of most of them. Competing interests: None declared
Primary Care is the front line in the battle for a healthy world. 26 April 2008
Alexander SD Spiers, Professor of Medicine (retired). N/A. Send response to journal: Re: Primary Care is the front line in the battle for a healthy world.	I agree emphatically with Iona Heath that making primary care available to everyone is of central importance in improving the health of the world. It shares this position with the provision of adequate nutrition and public health services (disease control, sanitation, clean water) for everyone. Who should deliver primary care? Doctors, nurses and primary health care workers should all play a part. This is not a competition; there is more than enough work for everyone. The diagnosis and treatment of disease is principally a doctor's job, but nutrition, hygiene, and the care of children and pregnant women can in most cases be managed very well by other health care workers. Why is progress in primary health care so slow, when it is not a matter of high technology and complex infrastructure? Surely the reason is political. An ivory-towered National Institute of Medical Research is good political capital, while ten thousand barefoot doctors, though much more useful, do not attract votes. In a developing country I saw an expensive research institute with hundreds of the poor living in squalid hovels in the grounds. Physicians, as well as politicians, are sometimes to blame.In another developing country, the doctors wanted supplies of a very expensive anticancer drug, when funding for vitamins and antimalarials was inadequate. The best and brightest medical graduates hope to practise high -technology medicine, and many graduates in developing countries leave their homelands in order to do so. Perhaps the real core of the problem is that primary health care is neither glamorous nor well-paid. Competing interests: None declared