Working with the community

General practitioners could gain much from greater involvement

When viewed from hospitals or the Department of Health, general practitioners may seemembedded in their local communities, ideally placed to act as “the patients' advocate.”1 But the view from an underprivileged housing estatemay be that the local practice is just as remote as the local teaching hospital. Althoughthe Health of the Nation asserts that many of the solutions to long term health problems are outside the remit of traditional heath services,2 general practitioners still regard health mainly in terms of the medical needs of individual patients and families. If general practitioners and the primary health care team are fully to represent their patients' wider health needs they will need to find ways of relating to their communities that go beyond merely understanding the epidemiological data.

“Community” implies a shared interest or geographical locality.3 If the primary health care team is to work more closely with local people it will have to consider what communities exist within its practice population. If it is going to ask people their views it will need to value the replies and be prepared to look for ways of responding to them. It will have to recognise how people become motivated to learn about health and the value of peer group support in this process.4 In future, health professionals may need to see their skills as one part of a wider partnership in which the contribution of patients to their own health has equal value.

Existing methods of hearing patients' views focus on the surgery, tend to be one off events, and are rarely central to planning. Surveys of patients' satisfaction tend to ask the questions important to the primary health care team and may miss the issues of real concern to patients5: often all they do is “endorse the status quo.”6 Patient participation groups can extend the possibilities of dialogue but tend to follow a practice based agenda, and critics highlight the fact that their members are rarely representative of the practice population.7

What is required, as Local Voices suggests, is “a radically different approach to that used in the past.” The primary health care team will have to link with a wide range of community groups and informal networks to reach those most at risk of ill health, who are often those least able to voice their concerns. The team will need to use methods, often qualitative in nature, that will enable patients to express their views freely. This will require a new way of working for most health professionals, who must be prepared to develop or seek out the new skills required.8 They may learn from other agencies--for example, schools have developed mechanisms, such as parent-teacher associations, school councils, and parent governors to listen to the views of parents and children.

Several general practices have published accounts of their attempts to seek out their patients' views.9 10 11 12 Their methods have included suggestion boxes, surveys and interviews, focus groups with patients or existing community groups,13 and collaboration with other local agencies and groups.

Practices seem to be most successful when they use a variety of methods and are committed to involvement with the community as a continuing process. In one study practices reported that the information that they gathered contributed to their ability to provide services in more equitable and acceptable ways for local people.9 In time they hoped that the need for medical intervention might also be reduced. Far from making huge and unreasonable demands, patients often make practical and achievable suggestions--such as changes to appointment times or to the message on the answering machine. Instead of running conventional health promotion clinics for a few worried well patients, practices may, for example, be invited by a women's group to run a stop smoking class in the local community centre. As this responds to a felt need rather than an imposed need it is more likely to succeed.14 Social problems are often identified, such as damp housing or the lack of “things to do” in the area. While not strictly medical, these nonetheless affect people's health. Raising awareness of the problem can often help to solve it--in south London, for example, the results of a practice survey enabled local people to negotiate for a better bus service.11 In other areas needs assessment has stimulated local people to find their own solutions to problems, through self help groups, befriending schemes, or activities such as food cooperatives and children's breakfast clubs.11 12

Building links with the community takes time, and the early stages of any initiative may be frustrating as people learn to work together and trust each other. Many practices, recognising the difficulties of doing this alone, now employ a patient liaison officer15 or link worker, whose job is to seek patients' views, forge links with other local agencies, and help set up health promoting activities based on patients' concerns. Other practices work closely with community development workers,11 12 who, because of their training, can stand back from the “medical model” and see health, as most patients do, in much broader terms. Because these workers are separate from the practice, patients are often more willing to share their feelings with them, and they in turn are better placed to accept and pass on criticism than someone in the team.11

Health authorities, in their role as purchasers, are looking at ways of carrying out needs assessment, and many have identified the general practice as the logical local unit with which to work. But to gain a sound knowledge of their local area general practitioners need to be prepared to fight the inevitable pressure to achieve rapid and measurable health gains overnight and to argue for the necessary extra resources, protected time, and access to skills. Only then will they be able to build a more complete picture of the community and achieve health gains, which may be both unexpected and difficult to measure.

Many general practitioners may find it difficult to see past the ever increasing demands of patients and the new contract. The current emphasis on patient's charters and consumer rights exacerbates this. Yet a clear view emerging from those general practitioners who have cultivated links with the community is that working like this can greatly improve job satisfaction.9 When the community participates in discussions about the realities of health care patients' expectations often become more realistic. Equally, doctors, by learning about resources available within the community, are better able to address the wider issues affecting people's health and to suggest more appropriate solutions to their patients' needs.12 At a time of low morale among general practitioners these findings are surely relevant.