Unfulfilled potential of primary care in Europe
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4469 (Published 24 October 2018) Cite this as: BMJ 2018;363:k4469
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Citing the Alma Ata Declaration, Allen and colleagues call for community level prevention to realise the Declaration's vision of health for all (1). That is correct as far as it goes. But the article fails to refer to the Declaration's call also for national level anti-poverty measures to address the wider economic and social determinants of health (2). That is surely a necessity for health for all in today's austerity environment, not least in the United Kingdom.
1. Allen L N et al. BMJ 2018; 363:k4469
2. Primary Health Care. World Health Organization, Geneva, 1978
Competing interests: No competing interests
Dear Sir,
In the interesting article 'Unfulfilled potential of primary care in Europe'(1) we lack two important concepts.
1. The role of the GP in his/her personal relationship with patients, personal and professional, defined as working in partnership to provide structure, guidance and support to take a complete look at the patient’s current state, including the assumptions and perceptions about him/herself and others e.g. family member(s); to set relevant and realistic goals, based on their own nature and needs; and to take relevant and realistic actions toward reaching these goals. (2-4)
2. To meet these goals and develop a personalized medicine, we need to develop and integrate a self-administered computerized system with built-in decision support that can serve to guide future implementation projects for tools of personalized medicine, such as health risk assessments in a personal health record. (5-6)
We admit that the approach set out 40 years ago by Alma Ata, and the conditions required to realise its potential were not known at that time, but there have also been positive evolutions to mention since then--e.g, computer and internet facilities, more informed patients, patient preferences, more shared decision making.
1. Unfulfilled potential of primary care in Europe.BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4469 (Published 24 October 2018) Cite this as: BMJ 2018;363:k4469
2. Saultz J. Personal Primary Care. Fam Med. 2016 Feb;48(2):89-90.
3. Richards H. We must defend personal continuity in primary care. BMJ. 2009 Oct 6;339:b3923. doi: 10.1136/bmj.b3923.
4. Weingarten M. Personal Primary Care: Understanding why therapy sometimes fails. Can Fam Physician. 1992 May;38:1167-71.
5. Krist AH, Woolf SH, Bello GA, et.al.. Engaging primary care patients to use a patient-centered personal health record. Ann Fam Med. 2014 Sep-Oct;12(5):418-26. doi: 10.1370/afm.1691.
6. Orlando LA, Hauser ER, Christianson C, Powell KP, Buchanan AH, Chesnut B, Agbaje AB, Henrich VC, Ginsburg G. Protocol for implementation of family health history collection and decision support into primary care using a computerized family health history system. BMC Health Serv Res. 2011 Oct 11;11:264. doi: 10.1186/1472-6963-11-264.
Competing interests: No competing interests
There is strong evidence that community pharmacy can play a large role in health promotion and prevention. Community Pharmacies across Europe offer accessible healthcare to the whole population, including people from under-served groups. They are open for long hours and appointments are not necessary. They are staffed by people from the local community who understand the local culture. The evidence is strong for smoking cessation, sexual health, CHD prevention and diabetes prevention and growing in areas such as weight management and brief interventions for alcohol use. Commissioning of these services via local authorities in the UK has been patchy and there are fewer commissioned services than in the past.
Community pharmacy teams are also very well placed to support patients with long term conditions to reduce their risks through healthy behaviours, patients will be in regular contact with community pharmacies to collect their prescribed medicines. This provides a great opportunity for secondary prevention.
At a time when pharmacists In the UK are increasingly working in general practice and can provide a strong link between surgeries and community pharmacy Is it time to further align the primary care contracts so that much of the primary prevention can be done in pharmacies who are at the heart of communities?
Competing interests: No competing interests
Re: Unfulfilled potential of primary care in Europe
Thank you so much for such a brilliantly clear summary of this important issue!
In 2015 we formed The Deep End Yorkshire and Humber group and have been working towards health equity by leading on 'Workforce, Education; Advocacy and Research' (WEAR) in our region(1).
You state in the article that "primary care colleagues believe the social determinants are not their responsibility" I would suggest that it's more that we feel powerless to make system changes in the face of unmanageable workloads. For example this week it has taken three hours of my time to engage with the local safeguarding team about just one family. We know that GPs who work in more deprived areas are more prone to burn out and resilience is a responsibility of the system not just individuals (2).
Much needs to be done to allow GPs time to come up for air (in the UK system at least) before they will have the 'headspace' to embrace the fantastic intersectoral dream we should be striving for.
References
1) Walton L, Ratcliffe T, Jackson BE and Patterson D.
Br J Gen Pract 2017; 67 (654): 36-37. DOI: https://doi.org/10.3399/bjgp17X688765
2) Eley E, Jackson B, Burton C and Walton E.
Br J Gen Pract 8 October 2018; bjgp18X699401. DOI: https://doi.org/10.3399/bjgp18X699401
Competing interests: No competing interests