It’s health care – not parts care
Bonnie Sibbald’s approach to the question of who should lead the
primary care team appears rather simplistic.1 Patients in my country
certainly would not accept the limitations of the UK system, and many of
the UK ex-patriots readily share their amazement of being able to access
necessary care without fuss and having their care coordinated by their
The main question to be posed should be: what is medical care
supposed to achieve, and how is this best achieved? Patients (and most
doctors) would propose that medical care should achieve good health, good
health being the subjective experience of the people, regardless of the
presence or absence of pathologies.2
Hence, health as a holistic concept cannot be reduced to
'instrumental care' of the parts as is the emerging tenet of disease-
In terms of the workings of consultations we know that firstly
effectiveness is based on knowing each other, and secondly we know that
the most important reason for the consultation is usually revealed with
the door knob in the hand – regardless of whose hand it is.2-5
Trivial consultations for minor ailments and complaints are on the
one hand a means for doctors and patients to gain knowledge about each
other, on the other they are the ‘entry to care’ for significant –
typically psychosocial – health problems. Having a good knowledge base
about the patient is fundamental in the context of consultations dealing
with high levels of uncertainty and complexity.2-5 Withholding such
information by diverting patients to ‘instrumental care’ of minor
complaints can only mean less effective, more costly and more dangerous
decision-making when it matters most.6
Primary care aims to be holistic, disease-specific managed-care is
fundamentally fragmentatory and ‘anti-holistic’. Team care that builds on
the specific skills of – ideally practice-based – health professionals in
the context of the whole person enhances care, cost-containment and health
– the way people experience it, even if the underlying pathology persists.
Viewed form a system perspective one needs to accept that systems
function according to their design. Monetary driven health systems are
designed to achieve monetary outcomes; health incentive driven health
systems are designed to achieve ‘patient health’, Incentives work – so be
careful what you bargain for.
And finally, it should be highlighted that the Cochrane review
referred to prefaces that the studies it is based on were all of poor
quality!7 How does this fit with the notion of ‘good evidence’?
1. Sibbald B. Should primary care be nurse led? Yes. British Medical
2. Sturmberg J. The Foundations of Primary Care. Daring to be
Different. Oxford San Francisco: Radcliffe Medical Press, 2007.
3. Hjortdahl P, Borchgrevink C. Continuity of care - influence of
general practitioners' knowledge about their patients on use of resources
in consultations. British Medical Journal 1991;303:1181-1184.
4. Hjortdahl P. The Influence of General Practitioners' Knowledge
about their Patients on the Clinical Decision-Making Process. Scandinavian
Journal of Primary Health Care 1992;10:290-294.
5. Gulbrandsen P, Fugelli P, Hjortdahl P. Psychosocial problems
presented by patients with somatic reasons for encounter: tip of the
iceberg? Family Practice 1998;15(1):1-8.
6. Hart J. Expectations of health care: promoted, managed or shared?
Health Expectations 1998;1(1):3-13.
7. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B.
Substitution of doctors by nurses in primary care. Cochrane Database of
Systematic Reviews 2005.
Competing interests: No competing interests