Primary care: core valuesPatients' prioritiesBMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7153.260 (Published 25 July 1998) Cite this as: BMJ 1998;317:260
This is the last in a series of six articles reflecting on the core values that will underpin the development of primary care
Series editor: Mike Pringle
How to run a 24 hour system of general practice has been a bone of contention between general practitioners and the public in recent years. 12 Doctors are loath to continue doing their own on-call work at nights and weekends. 34 Patients, however, prefer to see their own doctor or a general practitioner from their own practice, 56 where the service may be better,7 rather than a doctor from an agency that provides the on-call service. 89
This is the nub of the difference in perception between doctors and patients (and to some extent between healthcare professionals and the general public) about the quality of service they would like to see, and that difference in perception is one which needs to be taken seriously. When asked, patients express a wish to be involved in planning services and their delivery, 1011 and practices find this process worthwhile. 1112 And yet, radical changes in out of hours services have occurred without overt consultation with patients.
The conflict between the priorities of patients and the aspirations of general practitioners and their teams can be overcome to an extent by increased communication and patients' participation
Primary care services could do much more to meet patients' needs through offering extended advocacy
Vulnerable and other groups will increasingly look to primary care teams to lead community action on housing and benefits, as well as ensuring equal access to high quality health and social care
The starting point
General practitioner service in particular, and primary care services in general, are the jewelin the NHS crown for much of the British public.13 There is no doubt that the vast majority of the population regards the general practitioner as the first port of call for health care, and as the health professional who they trust to give them advice and treatment. They recognise the need for a guide through the maze of services that make up this increasingly complex health service.
A simple first priority for most patients is getting really good advice from their primary healthcare providers. That advice includes such details as the best treatment for a particular condition and the downside to it14; by whom or where that treatment would be provided; and where the highest success rates are to be found. Indeed, there is some irritation among the general public at the profession's lack of openness about success rates from procedures, although some evaluations are available.15
People point out that doctors always know where, and to whom, they would go to be treated for particular conditions, and where they would send their family—and patients cannot see why that kind of information should not be directly available to them. They access this knowledge indirectly through the general practitioners' choice of referral, but objective evidence on which to judge specific hospitals, units, and consultants is still not available, although some will be provided in the near future.
It also has to be recognised that patients may define success differently from healthcare professionals, and that increasingly the public expects to get its definition of quality and benefit recognised. The emphasis on biomedical outcomes used by healthcare professionals or health economists has to be tempered by a recognition of patients' definitions of outcome.
This applies to preferences concerning general practices themselves. While partnerships get bigger and teams more complex, patients express greater satisfaction with smaller practices,16 practices that are not involved in training,17 and those that run personal registered lists.18 Patients seem to be valuing different characteristics to those given greatest priority by general practitioners, and this will inevitably lead to tensions.
Patients want to know what the choices are for people with various forms of chronic conditions and where the best alleviation can be found. These days they expect to have access to a full primary care team 1920 and to be advised to use alternative forms of health care if they seem valuable—notably osteopathy and chiropractic, but also aromatherapy (for some end stage cancer patients and for women who have chronic severe mental illness) and acupuncture (for intractable pain). That advice is now seen as part of the armoury for living with illness and chronic conditions and therefore as a part of healthcare advice that people expect from the primary care team.
The general public puts high priority on out of hours services. That applies to the on-call service and to the sense of general lack of availability of primary healthcare services over public holidays. There is an increasingly strong feeling that primary healthcare services should be available, at least in part, on some of those holidays, so that the public is not kept away from those services for up to four days over Christmas and Easter.
This applies especially to certain groups of patients and their families. If primary care is tomean anything to much of the population, it has to be based on the notion that people live with families, partners, or carers and that part of the role of the primary care team is to care for the rest of the family. So, for instance, the fact that services are not available for four days over some public holidays makes many of those who live with severely mentally ill people angry and renders them helpless. There is a strong feeling that primary care services for certain groups, notably mentally ill and elderly people, should be better in general and more widely available in terms of hours of service.
Extending the concept of primary care
Patients often report that they express their views to members of the primary care teams but are not listened to. They feel that their priorities are different from those of the practice team and that there should be more fundamental questioning of whom the service is for and how it can be provided more in accord with patients' needs.
Patients want to be listened to,10–%12 both about their demands for health care and in general. The increasing availability of counselling in primary care is certain evidence of the need for listening of professional quality.21 The problem for many patients is the variable quality of counselling services offered, from thoroughly trained professionals to those who have attended only a short course. The British Association for Counselling's register and gradual licensing of counsellors is much to be welcomed, but it needs urgent implementation. The concerns of members of the public about quality of counselling and the amount of counselling they are offered in primary health care need to be addressed.
Patients also want a wider range of services to be easily available, be it physiotherapy (always much in demand and something that could be made available in larger practices), podiatry, osteopathy, or consultant sessions for common conditions that require referral. But it is not only healthcare services that the public wishes to see. As primary care expands its range of interests and skills, it becomes more essential that we should see primary care centres as one-stop shops for services that are determinants of health. These include housing and some social services in addition to the current system of health care.
This is not to suggest that all housing offices for a local area should be made available at health centres—rather, elderly people and people with enduring mental illness or learning difficulties could receive specialist housing advice from representatives of local authorities or housing associations based within the health centres.
That is equally true of advice on welfare benefits, and there is good reason to think of Citizens' Advice Bureaux operating from within health centres along with social services, especially those that are targeted at people with chronic poor health. It is extraordinary that, in Britain's well developed primary health care system, so little development of joint premises for health and other services has taken place. Since primary care is going to be increasingly the focus of services, and the gateway to them, it is essential that other services are to be found under the same roof. Only that way can a primary healthcare worker be certain that adequate social services are being provided for a very dependent patient.
It could be argued that general practitioners and other primary care workers, such as district nurses, should be orchestrating the services that enable people who are severely handicapped to stay in their own homes. That is particularly important for elderly people, and the role of the primary healthcare team in ensuring that elderly people stay in their own homes as long as possible, properly supported, clearly needs further development. Primary care teams can orchestrate services for elderly and other patients only if their access to other service providers is good—one reason at least for social services and housing to be located in health centres.
Members of the practice team as advocates
The public looks to health professionals, and particularly general practitioners, to help them to access services. However, the reality is that the advocacy role—so often claimed by primary healthcare professionals—needs developing if helping obtain access to services is to become a major role.
Just as mental health requires an integrated approach, services for elderly people raise issues of access, advocacy, and coordination. The range of models—from services managed by general practitioners or nurses to low key units offering outreach of specialist care from the acute section (as has been so successfully piloted by Lambeth Community NHS Trust)—requires active management. As the movement of services out of hospitals continues, the role of the primary healthcare team in delivering inpatient services for less acute conditions will need to be explored, including a possible return to provision of local cottage hospitals. Such a choice may be valuable for elderly people and their families.
Meanwhile, the public is worried by ownership of nursing homes by general practitioners—a move that creates a conflict of interest and undermines doctors' advocacy role. In the light of more general anxieties about standards in nursing homes, the primary healthcare team could act as an impartial unofficial inspection team of these and other community based institutions, since their interest must be the patients' welfare, rather than the profit motive of the owner.
Lastly, there is a perceived need for general practitioners and primary healthcare workers to act as advocates of particular groups of patients. Where the patient group is genuinely inarticulate and these patients have no one else to stand up for them, health professionals may play a vital role—a role that is limited at present.
This article has been adapted from Primary Care: Core Values, edited by Mike Pringle, which is published by BMJ Books.
There is always a danger when health professionals take on the mantle of the patient's advocate or friend: professional interests and concerns can differ from personal ones, and some distance needs to be maintained. Nevertheless, the public expects the primary healthcare team to orchestrate services, advise, inspect services, and educate.
Competing interests: None