Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK
My programmed response is always to jump to the defence of primary care, but a report entitled “Chronic Failure in Primary Care” that was recently published by the Grattan Institute, a public policy think tank in Melbourne, Australia, raises interesting challenges.
It was written by Jo Wright, Hal Swerissen, a health policy expert from LaTrobe University in Australia, and Stephen Duckett, an economist who will be known to many Canadians from his time in Alberta. It is critical and challenging but behind the headlines there are some constructive ideas.
What lessons might we learn? This report is tough on primary care, criticizing the management of chronic disease including heart disease and diabetes. Its authors say that the Australian primary care system provides only half the recommended care for many chronic conditions with a quarter of a million admissions for health problems that could potentially be avoided. While they recognize the importance of social, economic and environmental factors in preventive medicine, they say there could be much better outcomes with good primary care services pointing out that recommended care is not always provided and recommended treatment outcomes are often not achieved.
Behind these negative messages, however, were some positive suggestions for change. And, more important, the authors value primary care and explore how it could be strengthened. They believe that the current primary care model of care is wrong as it was designed to deal with the diagnosis and immediate treatment of acute episodes of illness. They say the system should be changed from fee-for-service payments for one-off visits to integrated care that might take a more holistic view of patients in the context of long-term outcomes. They also promote the concept of primary care networks that would assume greater more responsibility for local services in a coordinated approach that included targets and incentives.
Changing the model of care will be a challenge. It’s difficult, when trying to meet the day to day needs of practice, to stand back and take a more system based global view of primary care, and it’s particularly difficult for individual doctors to take a leadership role. What’s more, if it’s a criticism of a system in which you work, it can feel like a personal slight on your commitment to good care. The Royal Australian College of General Practitioners were defensive, saying they used old data and selective reporting and, using an argument with which we would all have sympathy, they say they need Australian solutions to Australian problems.
But, every so often, we need policy experts to challenge us about what we do. Canadians can read this report dispassionately and without feeling that it’s a personal attack on their own system. But, the demographic changes in Australia, together with the rise in chronic disease, and a not entirely dissimilar health care system, mean that the issues addressed have particular relevance. Reading an evaluation of the Australian system allows others to reflect more objectively. And, in this case, knowing Stephen Duckett’s involvement, there is extra interest.
General practice is under pressure elsewhere. In the UK many feel as if there has been a government media campaign to discredit primary care services in spite of the immense work in service provision, a rise in consultation rates, and increased transfer of care from hospital to the community. In response, my own colleagues in Northern Ireland created a video promoting the values of general practice with the message that “when General Practice thrives, the NHS survives”.
Our colleagues in Australia have been criticized, and in the UK general practice has been under pressure for some time. Looking at other systems always gives us an opportunity to look at ourselves. I sense that general practice and its fundamental structure will have to change. The system is outdated, the design is unsustainable, and the outcomes difficult to measure. But no one knows quite how it should be remodeled for the future.
Is there anything really new in this report? And yes, I just read it. Nowhere do I see any mention of the art of the possible–as in, WHY are patients with chronic diseases not getting all their checks done? Could it be that there simply is not enough time in the average GP day to get everything done that should be done?
There is reference to the UK QoF system as an exemplar and yet, the last decent review I read of that system questioned whether it was effective.
Ultimately the report is somewhat confusing. It ducks the issue of how we can best prevent obesity and diabetes–an integrated health and food policy is what is needed, not more pressure on GPs to push weight loss strategies with dismal long-term results. They do at one point acknowledge the need for a big societal shift but mostly shy away from the difficult political decisions needed to reduce chronic illness rates.
It points towards, but does not articulate, the biggest problem with doctors doing chronic disease management—-that it is alien to our training, to our curricula (both official and hidden) and to our inclinations. Put simply, doctors are trained and are skilled at managing acute illness. Not at managing chronic illness.
In the UK and to a lesser extent in Canada, we have found ways of compensating for that deficiency–we get nurses to provide chronic disease management. Nurses tend to follow the protocol. Doctors tend to take short cuts.