Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK
Shakespeare’s Warwickshire was the background to last week's 46th Annual Scientific Meeting of the Society of Academic Primary Care (SAPC) where Professor Christine Ennew, Provost of the University of Warwick, introduced the meeting by emphasising the importance of primary care in the development of their young medical school. She also underlined her belief in the transformational power of universities and how their contribution to academic medicine can alter clinical practice.
It saddened me that her optimism and enthusiasm contrasted with the stark reality of general practice as outlined by Candace Imison, Director of Policy at the Nuffield Trust, an independent UK health policy charity. She painted a picture of a UK national health service that was underfunded, understaffed and overstretched. It wasn’t just evidence from policy research, including from the British Medical Association (BMA) and the Kings Fund but she described how a letter received by her parents from their GP practice that made the greatest impact. They had written to all their patients, pointing out the difficulties they had in providing the quality of practice that they wished. Their letter included concerns about the lack of GPs in the training pipeline, that primary care was in terminal decline, and that it was a difficult job that was probably going to get more difficult. And, they also pointed out, if patients wished to see a particular GP, it may entail a delay of 6 weeks.
She had no clear solutions but one striking observation was that it appeared completely bizarre to try to meet the diversity and complexity of patients’ medical conditions within a 10 minute consultation - and this applied not just to older patients with multimorbidity. She recommended restructuring the primary care team to align skill mix with case mix and that it was important to think about the working lives of doctors and more segmented roles in primary care. She cited positive examples of practice evolution including an enhanced pharmacist role, the use of paramedic practitioners, an extended nursing role, physician associates, an increased supporting workforce that may include medical assistants and health coaches, together with the integration of new technology.
Perhaps the most disheartening aspect for me was that it all seemed so familiar - surely these were the principles behind the primary care team that had been promoted so effectively in the 1980’s. Rather than simply rebrand the previous model, we should also perhaps ask where it all went wrong before, and how we can we make it work in the future. But, Imison emphasised, it was not simply a matter of team re alignment but that general practice also needed “more of everything” and reminding us that, if primary care fails the UK’s national health service fails.
Multimorbidity is not just an academic construct. “Too many people giving too many answers and you end up on too many pills”. This was the succinct description by a patient to Polly Duncan while she was developing her multimorbidity treatment burden questionnaire for the 3 D study. Other patients' reflections included “going on holiday becomes a monumental task” and “Always having to give the same story….never seeing the same person twice…practitioners always asking the same questions…always getting the impression the file has arrived at the same moment as I have ...wouldn’t it be nice to see someone who knows who I am”. It is difficult as a doctor not to feel moved while listening to these descriptions of the burden of multimorbidity.
Multimorbidity has other major implications. Ongoing research by Jose Valderas examined how late diagnosis related to multimorbidity may contribute to poor cancer survival. The largest gaps seems to be in the diagnostic interval – the time from first presentation to referral. Pre-existing conditions may complicate the process and delay diagnosis either due to the competing demands of these illnesses or alternative explanations. Multimorbidity also influenced mortality from atrial fibrillation as Bhuatesh Jani pointed out in his work that examined data from the UK Biobank cohort. We already know this from the CHADS2 risk score that incorporates other cardio metabolic conditions. But, if you have one or two conditions in addition to atrial fibrillation, your mortality increases by a factor of three, and if more than three conditions, your mortality increases by six. Frances Mair pointed that current stroke guidelines are not fit for purpose because they ignore co morbidity.
In the “elevator pitch” session Carol Sinnott’s talk caught my attention. She highlighted the problems of trying to stop older people from driving if they are unfit. If a family doctor resists signing a fitness to drive form, it can cause such upset that even patients who have been with a practice for 25 years might leave the practice. Yet another problem unique to general practice that they do not teach you about at medical school!