General practice and public health: fostering collaboration for better health for populationsBMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2916 (Published 25 November 2021) Cite this as: BMJ 2021;375:n2916
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Rae and Marshall provide an accurate analysis of the unique opportunities that general practice and public health could have in supporting one another and the great potential there is to provide health for all.(1) However, they are also correct in highlighting some long standing challenges including: re-organisations, high workloads, capacity and resourcing.(2-4) If the government is committed to improving the nation’s health and levelling up then there are clear and pressing actions that are needed.
Workforce shortages in general practice need to be tackled urgently.(3-6) But it is important to note that these shortages are not equally distributed across England.(7) Despite having a greater burden of chronic disease, areas with higher levels of deprivation tend to have fewer GPs relative to the patient population. It is of great concern that there is now evidence that demonstrates the existence of an inverse care law, within general practice.(7,8)
This workforce crisis in general practice not only affects patients but the health of the members of the general practice team is also being damaged. In the case of GPs there is growing evidence that high stress levels are contributing to poor mental well-being, exhaustion, and burnout.(5,6,9,10). Not surprisingly, there is also research that indicates that burnout affects the quality of patient care.(11,12) In the future we need to be systematically measuring and promoting the health and wellbeing of GPs and other members of the general practice team.(4,13)
In relation to public health, there are also capacity and resourcing issues.(2,14-18) Over the last 20 years successive governments have made cuts to public health budgets. For example, the public health grant has been cut by 24% on a real-terms per capita basis since 2015/16.(16) Moreover, cuts to the grant have been greater in more deprived areas. If we are to prevent the early deterioration of health and tackle key public health issues such as accident prevention, air pollution, mental health, misuse of drugs, and obesity, then adequate funding will be needed. Longer commissioning cycles would also allow for planning ahead and provide stability for the workforce.(17)
We agree with Rae and Marshall that if some of the challenges are addressed then the general practitioners and public health specialists would be able to work more collaboratively and target individual and some of the root causes of ill-health.(1)
General practice is considered to be a key setting as there are many opportunities for maintaining and promoting the health of individuals and their families.(13,19) They are in contact with many people within their communities and the link with individuals can last many years, including those where significant health events occur. Besides knowledge about individuals, GPs and other team members such as social prescribers can have an intimate knowledge of the communities they serve, including information about local factors that may influence health. This presents opportunities for practices to play a greater role in targeting certain public health issues.
Calls to broaden the remit of primary care towards a wider public health role are not new and were included, for example, in the 1991 Primary Health Care Team Workshop Manual that supported a national programme of workshops.(20) If less has been achieved than hoped for, it will partly be a result of the resource and other constraints on general practice and the substantial cuts to public health budgets. The rhetoric on such working needs to be translated into effective actions, drawing on relevant evidence. In addition, where patient expectations of general practice are strongly focused on the priorities of illness and individual level prevention, an extension to public health actions may meet resistance.
In order to promote the health of communities and tackle inequalities it will be necessary to involve other settings such as schools and workplaces in collaborative working. There are also many important professionals and volunteers who are, or could be, actively involved. Teachers, police, social workers, environmental health officers, journalists and charity workers are but a few. Public health specialists have the skills to coordinate and support their activities.(17,21,22) They also have the vital skills of needs assessment, team building, programme planning and evaluation.
It is clear that many opportunities to prevent illnesses and implement actions on the social determinants of health are being missed and that there are growing health inequalities. Adequately resourced public health and primary care teams are crucial for promoting the health of our communities and reducing inequalities. With greater collaborative working the synergistic benefits emphasised by Rae and Marshall can be achieved.(1)
1) Rae M, Marshall M. General practice and public health: fostering collaboration for better health for populations. BMJ 2021; 375 :n2916 doi:10.1136/bmj.n2916
2) BMA. Funding for ill-health prevention and public health in the UK. May 2017.
3) BMA. Saving general practice. London: BMA, 2017.
4) Watson MC and Owen P. (2021) General practice on the brink: three key solutions the government must implement. BMJ 2021; 373 :n1482 doi:10.1136/bmj.n1482
5) General Medical Council. Caring for doctors. Caring for patients. London: General Medical Council, 2019.
6) Health Foundation Feeling the strain. What the Commonwealth Fund’s 2019 international survey of general practitioners means for the UK. London: Health Foundation, 2020.
7) Nussbaum, C., et al. Inequalities in the distribution of the general practice workforce in England: a practice-level longitudinal analysis. BJGP Open 2021; 5(5): BJGPO.2021.0066.
8) Hart JT. The inverse care law. Lancet 1971; 1: 405–12.
9) Hanson P, Clarke A, Villarreal M, Khan M, Dale J. Burnout, resilience, and perception of mindfulness programmes among GP trainees: a mixed-methods study. BJGP Open 2020; 4 (3).
10) Iacobucci G. GPs are at “breaking point” and in need of respite, leaders warn. BMJ2021;373:n1139.
11) Hall L, Johnson J, Watt I and O’Connor D. Association of GP wellbeing and burnout with patient safety in UK primary care: a cross-sectional survey. Br J Gen Pract 2019, 69 (684): e507-e514.
12) Hall L, Johnson J, Heyhoe J, et al. Exploring the impact of primary care physician burnout and wellbeing on patient care: a focus group study. J Patient Saf 2020 Dec;16(4):e278-e283.
13) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.
14) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761.
15) Watson M C and Thompson S. Government must get serious about prevention. BMJ 2018;360:k1279.
16) Finch D, Marshall L and Bunbury S. Why greater investment in the public health grant should be a priority. London: The Health Foundation, 2021.
17) Taylor K, Bhatti S, Ferris K and Avhad P. Overview – Narrowing the gap: Establishing a fairer and more sustainable future for public health. London: Deloitte, 2021.
18) Taylor K, Bhatti S, Ferris K and Avhad P. Identifying the gap: Understanding the drivers of inequality in public health. London: Deloitte, 2021.
19) Pereira Gray D. A Dozen Facts About General Practice/ Primary Care. Exeter: St Leonard’s Research General Practice, 2004.
20) Lambert D, Spratley J and Killoran A. Primary Health Care Team Workshop Manual. A Guide to Planning and Managing Workshops for Primary Health Care Teams. London: Health Education Authority, 1991.
21) Watson M and Tilford S, 2016. Directors of public health are pivotal in tackling health inequalities. BMJ 2016;354:i5013.
22) The Association of Directors of Public Health. What is a Director of Public Health (DPH)? London: ADPH, 2016.
Competing interests: No competing interests