Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK. He's giving the opening keynote address at the upcoming Swiss Family Doctors Conference 2015 in Bern, which focuses on core competencies in family medicine.
What is a family physician?
Many colleges and organisations have tried to define the core competencies of general practice. These include the College of Family Physicians of Canada, the Royal College of General Practitioners in the UK, and WONCA Europe with their definition of general practice /family medicine and the revised WONCA tree illustrating the core competencies and characteristics. Defining the role of the family doctor is difficult and Roger Jones, editor of the BJGP, pointed out recently, that “the job of the GP is as intellectually and emotionally demanding as many….and the breadth and depth of skills and knowledge required to do it properly are virtually limitless.” In addition, as family medicine is constantly evolving, there is the continuing challenge to integrate the best qualities from the past, critically evaluate our current role, and identify how we need to develop in the future.
Are you a good doctor?
Personal and continuing care have always been considered core values in family medicine. Denis Pereira Gray, a pioneer in academic family medicine, emphasised the importance of personal care in his major paper published in 1979, and, even in 2015, still emphasises the importance of continuity of care.
Similarly, in his seminal work, “Family Medicine. The Medical Life History of Families”, Frans Huygen, the father of academic family medicine in the Netherlands describes his patients in detail, shares their personal lives and relationships, and points to the complex patterns of health and sickness that weave continuously through families.
In 1981 the Royal College of General practitioners published their report “What Sort of Doctor” which included as their core skills: Professional values; Accessibility; Clinical competence and; Ability to communicate. As a registrar I charted the views of patients in my training practice against these core skills- the findings later published as a letter in the BJGP and the results were overwhelmingly positive. Patients seemed more than satisfied and many volunteered words of praise on this practice which was to be a benchmark in my future career. Later, in the Lancet, developing the theme of the personal relationship, we added the concept of personal significance to statistical and clinical significance and explored how, in unlocking the processes involved in the delivery of clinical messages to a patient, personal significance is the key.
Personal and continuing care have always been considered the foundation principles of good general practice. But, perhaps being a caring family doctor is not enough.
Are you an effective doctor?
A family doctor can be caring, empathetic, and accessible without knowing how well their patients are managed clinically and, in particular, the quality of management of chronic disease without measurement. Discussions around quality became part of the contract negotiations in the UK that lead to the introduction of performance indicators- known as the quality and outcomes framework. Initially introduced to improve doctors pay, the profession offered evidence based quality measures in return- performance related incentives comprising 25% of payment. This had an enormous effect on UK general practice and has been extensively researched. Overall, there were clear improvements in the management of those chronic conditions included in the quality incentive scheme although those not included did not do as well and there was some plateau in effect with time. Pay for performance is also well established in primary care funded insurance schemes in the US and the advantages and disadvantages of the UK and US systems are widely discussed elsewhere, including Australia, which has its own form of performance incentive payment although GPs receive 10% or less of their income from such incentive schemes. A joint OECD and European Observatory on Health Systems and Policies project gives a helpful overview of what some pay for performance programmes have achieved and some of the challenges.
While the UK quality incentive scheme has influenced process measures in chronic disease, one might ask if there is a relationship between quality of care and premature mortality. Surprisingly, it seems not and, although these results have been challenged, the debate continues. Similarly one might ask if there was an effect on emergency admissions for incentivised conditions compared with those not incentivised- and there was. This change was larger than might have been expected and the authors wondered if pay for performance schemes may have had impacts on quality of care beyond those directly incentivised.
Are you meeting the needs of modern medicine?
Despite evolving patterns of illness and changing societal demands, our general practice model has remained relatively unchanged for generations. It may be time to look more closely at how we deliver care and question what we do but this is both challenging and threatening. We might ask, for example, if continuity of care, which has always been considered a fundamental strength of good family medicine, could possibly be a weakness: A recent study found that doctor continuity in the 24 months before diagnosis was associated with a slightly later diagnosis of colorectal cancer, although, admittedly, the effect was small. Reflecting on paediatric family medicine research, a recent editorial questioned if primary care clinicians are adequately trained in child health for the changing skills they now require for practice. Multimorbidity is at the core of family practice and helps differentiate general from specialist medicine but we might ask ourselves if we manage multimorbidity well. Recently Bruce Guthrie pointed out that “We’ve exposed many of the weaknesses of single disease guidelines and quality indicators. But we haven’t put anything adequate in their place. We’ve opened up an intellectual space, but we haven’t filled it. No-one else is going to lead the way on this. It’s up to us, or the single disease paradigm will continue to dominate.”
Martin Marshall raises the possibility that what made general practice in the UK so effective in the past may now be a limitation- in particular its small scale, isolation, and lack of accountability. This may mean that general practice can no longer respond to the needs of the public and demands of the health service.
And, patients and politicians seem unhappy. The success of quality measures and performance indicators appears to have been at the cost of accessibility, leading to widespread media complaints by patients and politicians about poor general practice access. The Patients Association in the UK, in a report recently, also had some criticisms of general practice, particularly in relation to access and communication. Family doctors, too, are unhappy about what they consider to be doctor bashing while, at the same time and not unrelated, there are considerable recruitment problems. The combination of these many factors has created a very unstable and unhappy general practice environment. It seem unlikely that the current models of family practice are sustainable and, indeed, we might even question if it is the right model.
Are you prepared for the future?
Family medicine is going to change. The joint Nuffield Trust - Kings Fund document “Securing the future of general practice” identified the many pressures on primary yet, as GPs and their teams are so busy trying to respond to these pressures, they do not have time to think about how to provide and organise care for the future. They anticipate new models of care and a move to larger-scale organisations or networks with new services, different skill-mix, and fresh professional and leadership opportunities.
Simon Stevens, Chief Executive of the NHS England sees a new model for primary care in the UK and, senior fellows in his office, Harpreet Sood and Mahiben Maruthappu, discussed this in detail in a recent interview in CMAJBlogs. They see an expansion in the role of ‘expert generalists’, targeting services at registered patients with complex ongoing needs such as the frail elderly or those with chronic conditions. They see changes in primary care leadership to include nurses, therapists and other community based professionals and a need to dissolve traditional boundaries that exist between primary care, community services and hospitals. Practices will coalesce, amalgamate, form federations or networks becoming multispecialty community provider.
There is change ahead. The needs of modern medicine, increasing patient expectations and government demands mean that general practice probably faces more accelerated change in the coming years. It may be challenging to question some core values and ask if our current model of practice is fit for purpose but, we cannot hold unquestioningly to structures of the past but must constantly ask ourselves if we could do better for our patients.