Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK. He is currently attending the 2016 Primary Health Care Research Conference in Canberra, Australia
“This is the time to be in general practice...This is the time to be in general practice research,”
said Steve Hambleton, former chair of the Primary Health Care Advisory Group, a body created to look at options to reform care for people with complex and chronic illness. Steve gave the opening conference address. He spoke about the advisory group's work, their wide ranging membership including family doctors, other providers and consumers, and he outlined three areas that would be major challenges in the future: chronic care, obesity, and preventable disease. Steve also reminded us that those patients with the greatest number of diseases see the greatest number of doctors. The final report, delivered on March 31st 2016 was accepted and the Minister for Health endorsed their findings. Steve was upbeat.
Janet Quigley, of the Commonwealth Department of Health, expanded further. The implementation of the health care home model is a major change by government and she envisaged a tailored care plan, developed together with the patient, to identify appropriate goals. There would be risk stratification into a three tier structure based on the complexity of care and aligned with funding. The government were keen on data collection and continuous quality improvement and they hoped for a national approach to data collection and, in the long term, to recommend a national minimum data set. It is due to begin from July 1 2017.
During the discussion, there was emphasis on the necessity for external support for change management. There was also concern that the initiative would not influence the care of sufficient numbers of patients to generate enough funding for a fully integrated health care home. But, the most interesting question, and entirely appropriate at a research conference, was, "Why not do a trial?"
During the research papers session, I was interested to hear from Tom Brett and Diane Arnold-Reed, (University of Notre Dame) that familial hypercholesterolaemia is under recognised, under diagnosed and under treated and has an incidence of 1/200 to 1/500. Tom recommended screening medical records using an electronic tool because, although limited, there are so many genetic variations that genetic screening alone will miss 40%, but, if one identifies a patient clinically then pre-test probability becomes 1 in 2 for their relatives.
Tanisha Jowsey could have added to the burden of family doctors with yet another chronic illness management plan but, her anthropological background and amusing presentation added a refreshingly different perspective. She pointed out that a diagnosis of chronic illness means that a patient’s life expectations are completely disrupted and they cannot plan for the same future any more. In terms of a care plan, she emphasised that it is important to ask about how the chronic illness impacts on one’s life. A patient’s care plan might surprise us - their goal may be, for example, to be sufficiently well to dance at their daughter’s wedding.
Men and women with severe mental health problems die 20 year and 15 years early respectively. As Victoria Palmer pointed out, general medical care can be neglected in patients with severe mental health problems. They may not, for example, be taking their medication for diabetes or hypertension. Furthermore, she considered this to be a serious moral and ethical problem, and these are people who access health care frequently.
In her talk, she apologised for the 33-word research study title. One might prefer a short pithy title to catch readers’ attention like a newspaper headline. But, few people read paper journals and most researchers identify studies using electronic search engines. From an editor’s perspective and to an author’s benefit, it is essential that a research study title describes the method and contains searchable terms to enable other researchers to find and cite their work. A short clever title may look good on paper but the research may never be found.
Susie Fletcher, in describing her work on depression, also made an observation that caught my attention. Patients with depression do not change behaviour on their own. It is part of the condition and may be due to their poor executive functioning. Any intervention should therefore facilitate patients self care.
Obesity has many health implications but it’s also an equity issue, as Catherine Spooner pointed out, particularly as women of low socioeconomic status are more likely to be obese. Obesity diminishes self-esteem and also generates disparities. These women belong to vulnerable groups on many indicators, and the obesity stigma exacerbates their disadvantage.
Primary care policy was the main theme of the final plenary when Shaun Larkin of HCF Australia and Andrew Wilson of Medibank Private, explained why primary health care matters to private health insurers. Andrew listed the factors that are likely to increase costs: aging, chronic disease, and new technologies. His calculations were that 2.2% of patients consume 35% of all spending and that 70% of these have underlying chronic disease. The increase in premiums greater than inflation is due to utilisation. He did not like the term frequent-flyer; these are sick people who need health care. And, to add to future problems, as health care costs rise, the proportion of people in active employment who can fund this care is dropping. As pointed out by Shaun Larkin, health care cost are unsustainable. So, why is primary health care important? Apart from other reasons, it makes sound economic sense.