From vision to action in primary care

Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK. He recently attended the Society for Academic Primary Care annual conference in Exeter, England.

 

The declaration of Alma Ata, over forty years ago, was a key milestone in the development of general practice. Generations of physicians may remember how it defined their career. Dr Shannon Barkley, World Health Organisation Technical Officer for Primary Health Care Services and Family medicine, described the changes that have occurred since then, leading to the 2018 Declaration of Astana. Looking back, we can see why the Declaration of Alma Ata was so important and how the principles outlined are still as fresh and relevant as they then were. There has been progress although different countries move at different speeds. “Health for all by the year 2000” wasn’t achieved but the Millennium Development Goals” were quite successful and the focus has been, more recently, on universal health coverage. I asked Shannon to tell us a little more about the Declaration.

The declaration of Astana is a political declaration and we cannot tell if it will have an impact world wide but primary health care is now very much a part of the political language and landscape. I also spoke to Professor Jose Valderas about what the declaration will mean to individual countries.

Declining continuity of care is an issue in primary care worldwide. According to Dr. Anne Gaglioti from Atlanta, GA, continuity of care has become increasingly poor in United States and is not used as a measure of quality but may be driving some disparities in chronic disease management outcomes. Anne decribed her research on the relationship between personal and continuing care in an enormous population of Medicaid patients. Her group measured costs  and outcomes in chronic disease management and found that personal continuity had clinical benefits and lower cost. These finding may, however, be confounded in that competent patients are better able to access continuity of care while some patients are less able to advocate and organize for themselves in this regard. Anne explains her work further in this short interview.

Personal and continuing care has been at the forefront of research and teaching at the University of Exeter, the SAPC conference's host institution in 2019, for decades. I interviewed Professor Sir Denis Pereira Gray, an internationally acclaimed author on this topic, for his thoughts on continuity, given his recent research confirming that continuity of care reduced mortality:

Dr. Victoria Palmer from Melbourne, Australia, trained in applied ethics and is a qualitative researcher. She described her work as part of an innovative trial of integrating patients into the co-design of their care. Entitled “ The participation paradox re-evaluated: Individual and system value in experience based co-design”, The CORE study was about what happens when you involve patients themselves in the management of their mental illness. Co-design requires a lot of time and is also a burden on patients but the question is - does engaging in co-design improve psychosocial recovery.  I asked her to explain it further in this interview:

Other highlights of my SAPC conference included listening to Emma Wallace talk about her evolving research career in multimorbidity, the risks of polypharmacy, developing explicit measures of inappropriate prescribing, and designing interventions in deprescribing; hearing Professor Brian McKinstry’s insights on their work on video consultation and the difficulties they encountered (while patients are happy to carry out video conversations with their relatives all over the world, this research group encountered many difficulties in trying to establish video consultation); Marc Jefferies'  work on tech-related issues including research showing how doctors may simply switch off with too many medication alerts on their computer screens; and Sally Hull  presenting work showing that increased electronic access to renal physicians was great for general practitioners - who saw increased numbers of consultations for their patients - but not always welcome by the specialists, who felt overloaded.

This is the second of 2 blogs about SAPCASM 2019 - part 1 can be found here

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