Primary care: arriving or departing?

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.

 

Resources for primary care in the United Kingdom are under increasing pressure, as Dr. Jennifer Dixon, Chief Executive of the Health Foundation, outlined in her keynote address to the  Society for Academic Primary Care meeting in Exeter last week. A healthy growth in spending from about 1990 until 2008 was followed by a rather dismal change in the funding landscape: the proportion of overall health spending allocated to primary care gradually declined and has now been flat for the last 6 years at roughly 9%. Overall, however, spending on health as a percentage of GDP is about average within the EU and despite austerity policies, spending on health has been relatively well preserved compared to education, for example. When it comes to public satisfaction with primary care, the main problem mirrors what we see in Canada - access. Recent Social Research Survey data has shown that 83% of the public were satisfied with their primary care experience and 46.2% said that their overall experience with primary care was good or very good.

As in Canada, the primary care physician workforce in the UK is a problem. The overall health workforce grew from 2010 to 2018. However, an increase in the number of hospital doctors has not been matched in primary care as the overall number of fully qualified general practitioners  (GPs) has gone down. The main problem appears to be retaining GPs in their 50s. From 2015 to  2018, the number of fully qualified permanent GPs reduced by 1180 and, it wasn’t just the number but also their level of experience. Access issues are compounded by the relative patient list sizes per GP being greatest in the most deprived areas (where patients are likely to be sicker). Among GPs, there has been a large decline in satisfaction with practising medicine and, in particular, the proportion who are happy with time they can spend with patients. Similarly, the proportion of patients who report that the can see their preferred GP has fallen from 65.3% to 55.6%. The mode of practice has also evolved with more extended access, increasing online facilities and, new service models but with an overall decline in continuity of care. I asked Jennifer in a video interview how she saw technology changing practice in the future:

I ran into some rock star researchers at the conference. Aspirin has an undisputed role in secondary prevention of cardiovascular disease but there has been controversy over its role in primary prevention. Some recent papers in the NEJM, made a major impact and provoked considerable media attention and online discussion. I spoke to Mark Nelson of the University of Tasmania, principal investigator on the ASPREE study, which investigated the effectiveness of aspirin as a preventative therapy, and the largest clinical trial ever conducted in Australia about the impact of his work. It was fascinating to record his thoughts on the role of aspirin, not just in cardiovascular disease, but in cancer.

Still focusing on vascular disease, Suhail Sheik studied the possible effect of ethnicity on dementia diagnosis in adult stroke survivors. Despite had a large database (about 45K patients)  from the CPRD linked to Hospital Episode Statistics (HES) his study population was 96% white. He found a lower incidence of dementia diagnosis among, Asian and mixed race people compared with white, but the only finding to reach clinical significance was in the Asian group. He speculated that symptoms may be under reported for cultural reasons or possibly good family support among minorities meant that patients didn't necessarily identify to primary care.

Sinead McDonagh discussed her meta analysis that quantified the effect on mortality of a difference in blood pressure between two arms - which would add 2-5% more patients to the high risk category identified using the QRisk model. It was a useful reminder that it's always important to take blood pressure in both arms.

Jeff Lambert described his study of exercise based cardiac rehabilitation in patients with atrial fibrillation - interesting work bearing in mind evolving evidence of a link between sustained intense exercise and incidence of atrial fibrillation. But the question remains: is there any specific effect in those with atrial fibrillation or if it was simply that exercise rehabilitation improves the outcomes for all cardiovascular patients?

When a medical editor attends a conference it can be uncomfortable to hear what researchers think of journals! Professor Debbie Sharp highlighted a difficult issue faced by researchers trying to fund journal article processing charges. I have considerable sympathy with this problem, although its difficult to know what to do to support researchers as journals, too, struggle with budgets. For early career researchers, the publishing fee may represent a large proportion of their overall grant, and their research may not be funded by a grant funder that pays these charges. Grants may stipulate that any surplus at the end of tenure be reimbursed and this might occur long before any research papers have been submitted or published. Debbie makes a good point in this short interview:

Those of us involved with journals are also very aware of how the publishing world is changing.  Yin Yin Lu, from the Oxford Internet Research group offered some interesting insights into the future of medical publishing in a short interview with me:

Domestic violence is a common issue for patients presenting to primary care. This was the topic of Gene Feder's  thoughtful and thought provoking Helen Lester Memorial Lecture. I was taken aback when he pointed out that one in four women and one in seven men, experience domestic violence in their lifetime. The impact on women is disproportionately large. Interpersonal violence (IPV) occurs in the context of societal issues such as gender inequality and poverty. The primary care practitioner sees the end state yet the causes are upstream. Gene made us think about the different ways in which patients may present, not just from the direct results of violence but many other physical and psychological manifestations. Mental health consequences (and also possibly reverse causation), include depression post traumatic stress disorder, alcohol abuse, suicidal thoughts etc and it can affect children in many ways- and not just through maltreatment. Gene wasn’t afraid to ask difficult questions. If domestic violence is a clinical priority then what is the evidence of effectiveness of interventions? While underlining the importance of research, he pointed out that patients/victims, want to be asked, need an immediate positive and empathetic response,  and that doctors need to understand the chronicity of the problem and ensure follow up. The most important aspect, with the most robust supporting evidence, is for advocacy support for survivors such that we become IPV “aware” practices. Gene also asked us to think about the impact of adverse childhood experiences, and their possible influence on brain development leading to an increased risk of medical and psychological problems. As he talked I wondered about how often I had missed cues in the consultation to ask about IPV. I interviewed him after his talk and he was very candid.

 

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

 

2 thoughts on “Primary care: arriving or departing?

  1. Eden

    The annual conference showcases the latest research and education in academic primary care from the UK and around the world in keynote presentations, parallel sessions of verbal presentations, posters, workshops and symposia. The programme will also feature the above mentioned lightning presentations, poster pitches, a creative arts stream and  “The Solution Room” – an early careers workshop .

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