Responsibilities beyond the patient
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c6832 (Published 30 November 2010) Cite this as: BMJ 2010;341:c6832
Does a general practitioner in a mining area who encounters a cluster of emphysema cases have a duty to speak up about local working conditions? Does a doctor working in an area of high smoking prevalence have a duty to target the community with smoking cessation or other initiatives?
Speakers—including a GP and a public health pioneer—at a discussion hosted by the BMJ and King’s Fund in London last week were united in agreement that all clinicians do have a responsibility to the population as well as to the individual patient.
Iona Heath, president of the Royal College of General Practitioners, said: “In any collectively funded health system, GPs must find a way to balance the needs of the individual with the needs of the population. On the other hand, if you are an entirely private physician, and therefore it is the patient who funds you, you have no responsibility for the rest of the population.”
But she added: “GPs cannot do this alone. GPs and public health experts need to work much more closely together in the care of the population. A GP’s priority will always be to the individual patient in front of them. When seeing a patient in the consulting room, if your commitment is not absolute at that point then the patient doesn’t feel seen or heard. They are likely to construe any decision you make as not in their interest.”
But this focus on an individual patient “doesn’t mean we don’t have a commitment to the population,” she said.
Anna Dixon, director of policy at the King’s Fund, said: “I believe doctors need to take a population outlook as well as an individual outlook. Many causes of ill health lie beyond the individual. Our circumstances to some degree shape our health—for example, our environment, community, and wider issues in society such as unemployment and poverty.”
Ms Dixon gave an example of a GP seeing a patient with shortness of breath. The GP refers the patient to a respiratory physician, who diagnoses emphysema, and the patient is treated. “The GP has carried out their duty to the patient. But what if they saw a large number of cases? Perhaps there was a lot of mining in the area. Then the doctor has a duty to speak up.”
Time for action
Ms Dixon said that research carried out by the King’s Fund and the London School of Hygiene and Tropical Medicine on the effect of the Quality and Outcomes Framework (QOF) highlighted several barriers to a population focused approach. “QOF is very focused on secondary prevention rather than primary prevention. Secondly, GPs did not see they had a role in public health.” She added: “We need different incentives from QOF. And GPs will need time to step back from the individual patient.”
Elizabeth Paice, dean director at the London Deanery, said: “Our regulator, the GMC, is very clear that every doctor has responsibility for the health of the population.”
She added: “It is the duty of doctors to take on responsibility for the population.” She added that the way to do this was to engage the next generation of trainees.
Professor Paice, a consultant rheumatologist, said “We could make a huge difference to the outcome of rheumatoid arthritis, for example, by educating the population about symptoms so they are diagnosed earlier.”
Muir Gray, chief knowledge officer of the NHS, said doctors should be aware of and be bothered about variations of service delivery in their area, which might affect the health of a local population. Sir Muir’s office has just published the NHS Atlas of Variation, which plots variations in service and health across England. It shows, for example, a 50-fold variation in rates of transient ischaemic attack across the country.
Sir Muir, who helped pioneer Britain’s breast and cervical cancer screening programmes, said he didn’t expect all clinicians to have responsibility for the health of the population. Instead he proposed recruiting a pool of around 3000 doctors to do so. “We are proposing that the 3000 clinical directors in England would be responsible for thinking about the health of their local population,” he said. For example, a clinician in East Sussex would look at how chronic obstructive pulmonary disease is managed in the area and produce an annual report. Sir Muir said the 3000 clinicians would be given time and support to “think about where the action isn’t rather than where the action is.”
Professor Paice ended the session with the sobering thought that doctors did have some responsibility to UK taxpayers. “Doctors have a responsibility to consider the value of what they are doing in the context of the economic situation,” she concluded.
Notes
Cite this as: BMJ 2010;341:c6832
Footnotes
Competing interests: All authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.
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