Rick Glazier is Senior Scientist at the Institute for Clinical Evaluative Sciences, Family Physician and Scientist at St. Michael’s Hospital, and Professor of Family and Community Medicine at the University of Toronto. He is currently serving as President of the North American Primary Care Research Group (NAPCRG)
I see patients in a setting where there is an inter-professional team, electronic medical records, patient reminders for cancer screening, physician payment through capitation plus incentives, and after-hours coverage. These changes have all occurred in the past few years and they have been very costly to the provincial health system.
Most primary care settings in the developed world have undergone similar changes, or want to have them. Like my setting, very few places are able to say whether these changes have made patient care better, improved health, or reduced costs. Sure, we all know of success stories: a plan that has reduced emergency department visits; a group that has improved immunization coverage. But are these successes sustained over time and when they are successful do they spread elsewhere? The evidence from somewhere else, produced about a decade ago, suggest that these types of changes produce better health and better equity at lower costs. But what about right now, where I practice? Sadly, not much is known.
We live in a world that has started to recognize the promise of primary care to support health systems in a way that makes them effective, equitable and affordable. But few places have been able to back up that promise with results. Partly, our measurement systems are weak or non-existent. And in some places our primary care systems are thin on the ground and information technologies have not evolved far enough. The primary care systems with the best results have been innovating for many years. They are largely located outside of North America and they have surprisingly few commonalities in how they are organized.
So what do we need to learn from each other? A new initiative called Family Medicine for America’s Health has set out to improve access to primary care, be accountable for cost and quality, reduce health care disparities, move to comprehensive payment and away from fee-for-service, transform training, implement technology to support effective care, improve the research that underpins primary care, and actively engage patients, policy makers, and payers. Surely the U.S. health system is a unique case, so what can the rest of the world learn from this initiative? I will argue that although our health systems are vastly different, we all need to know what policies produce these sorts of changes, how they can be effectively organized and implemented and how we can tell if they are working or not.
An evidence base is needed so that all health care settings can realize the full value of primary care. The U.S. family of Family Medicine organizations has recognized the need for a robust research strategy into what works. So has the Canadian Institutes for Health Research and so have some other international funders.
There are many ways and many places that we can learn from each other. Still, it’s rare to have face-to-face opportunities to meet and speak with primary care clinicians, patients, policy-makers and researchers. NAPCRG has helped to foster a number of these opportunities, including interest groups, committees, working groups, pre-conferences and embassy conversations. NAPCRG’s annual meeting, about to start in Times Square New York, is a unique venue with more than a thousand attendees from many places across the globe, all eager to learn about primary care from each other. I don’t think that NAPCRG or its annual meeting will solve the world’s health system problems. But I can’t think of a better place to start.
This blog is part of a series on global primary care research hosted on CMAJBlogs.com to coincide with NAPCRG’s Annual Meeting (2014), which begins this weekend
And on the other hand….and I’m biased a bit by having trained and worked in FP in the UK tho am now working in rural PEI….we have the enormous amount of work done by Starfield et al which we have known about for some years now. Good primary care improves outcomes and reduces costs. Period. Should we, therefore, be taking a more wide-screen approach to primary care development? As in, rather than obsessing about, say, pros and cons of EMRs or the effectiveness of various nuances of consultation techniques, maybe we should be simply identifying those FPs who want to do a real good job and give them, within reason, what they need to do it? The inevitable contra-arguments from politicians and micro-managers will focus on trust and accountability for spending public money. To which I say, if you trust us to save lives or relieve cancer suffering at 3am when you are tucked up safe and sound in your beds, then I think you can trust us to give value for money and not defraud the public purse. And you do trust us to get on with it at 3am because you haven’t much choice in the matter. Another disturbance in the force of course!
To quote, poorly, a famous comment by a Lancet editor years ago. “We must find out what it is that the GP does and then support him doing it. Whatever it is that he does.”
We are not just preventive med machines—in fact I hold that the efficient and effective FP clinic should have FPs doing very little of that work because RNs do it better.
Nor are we just there to check out sick kids and reassure anxious parents
But we can and we do do that work—-but I hold that if we take a worldwide view of health care, we need a model of FP which provides reasonable care while minimizing dependence on doctors Keep the FP for the complex cases and have a good multi-disciplinary team for all the rest of it.
So, what is my point? What can I contribute to this discussion? Certainly I agree we need primary care researchers getting together but we are in danger of getting too deep into the trees when we ask What works? I met an excellent English FP once who told me how good care saves lives and he produced his death rates over a period of years. Is this the level of work we need to answer the question, What works? I recall in the early 90s when my practice got interested in asthma. We did not have new meds, we simply learned how to use what we already had and we used it better. Hospital admissions, out of hours calls, urgent daytime consultations for acute asthma simply vanished over a period of two years. QED, we said. We got our nurse trained up to take over and moved on to the next challenge.
So big indicators applied to relatively stable populations—is this the way to go?
Excellent points, Declan. Thanks for commenting.