FMCH Editorial Office
Today, as primary health care is facing challenges from several aspects, researchers of general practice in various countries have formulated corresponding reform strategy. Based on a comprehensive review of recent papers published in journals of general practice around the world, we outline current threats to primary health care, the possible future reform direction, and the determination of general practitioners (GPs) to assume social responsibility.
1. Three threats to general practiceT
1.1 “Division” of primary health care
Three papers published in the Annuls of Family Medicine, the British Journal of General Practice, and Family Medicine and Community Health have highlighted the declining continuity of primary health care in the United States, the United Kingdom and Australia [1-3].
In the United States, the decline in the continuity of primary health care is mainly manifested in the neglect of continuity in resident education, the continuous division and independence of many sub-disciplines (such as hospitalists, sports medicine, maternal and fetal medicine), coupled with economic factors and the impact of society on GPs’ career choices. The traditional integration model for GPs in the United States of staying in the community, home consulting, nursing homes, offices and hospitals since the 1960s is being strongly impacted with the risk of fragmentation. Because of this, both GPs and patients have paid the price. With the weakening contact with families and patients in the community, job satisfaction and sense of belonging of GPs begin to decline, while patients get lower quality medical services with increasing medical costs .
In the UK, this decline in continuity is manifested by the expansion of primary health care and the greater emphasis on the accessibility of primary health care by the National Health Service (NHS). In the past, close doctor-patient relationship based on small-scale primary health care teams and stable communities were influenced by population movements, general practices merging into larger ‘super practices’, increasing temporary work for primary health care physicians and personnel, and work pressure, which made it more difficult for patients in the communities to maintain continuous personal contact with the same GP .
Unlike the situation in the United States and the United Kingdom, Professor David G. Legge, in his commentary Striving towards integrated people-centred health services: reflections on the Australian experience, described the problem in the continuity of management and information in the primary health care system in Australia. The division effect of privatization and marketization brought by neoliberal economic policies is creating serious obstacles to the person-centred primary health care services.
The division first occurs between primary health care services funded by governments at all levels, such as the conflict of medical insurance payment between federal and state governments; second, it is manifested between public community health centers and private hospitals and clinics, for example, the difficulty in receiving efficient health care services in public institutions for patients who asked for psychiatric or dental care, while the government lacks the accountability of private hospitals, private specialists and private insurance funds. In addition, GPs often do not have complete specialist information to refer to their patients. Due to these splits, Australia’s primary health care system faces enormous challenges in carrying out community health prevention services, especially in social risk factors influencing health .
1.2 “Numbness” in primary health care
According to a commentary entitled OxyContin and the McDonaldization of chronic pain therapy in the USA published in volume 7 of Family Medicine and Community Health in January 2019, excessive emphasis has been put on the efficiency of diagnosis and treatment and accounting regulations in the primary health care system of the United States, which force many doctors to be induced voluntarily or involuntarily by performance indicators, using McDonaldized diagnosis and treatment for patients, that is, to pursue super efficiency with a calculable, predictable and controllable thinking of diagnosis and treatment, in order to treat more patients in a safer way in a shorter time.
But this McDonaldizationpractice will inevitably lead to the weakening of patient-oriented care and services and may even cause a wide range of medical risks. OxyContin, for example, is a potent, steady, durable analgesic that can be easily reimbursed by local insurance companies in the United States. Purdue Pharma, its pharmaceutical manufacturer, has publicly claimed that its addiction rate is less than one percent. Therefore, under the marketing of the drug company, many family doctors would prescribe OxyContin by instinct after identifying the degree of pain in patients through the 10-point Likert scale. They will not carefully consider causes behind the pain and the feasibility of therapy with no drug or non-opioid drugs, but just to ensure the efficacy of diagnosis and treatment and improve patient satisfaction. As a result, the annual number of OxyContin prescriptions in the United States has increased tenfold, from about 670,000 in 1997 to about 6.2 million in 2002, triggering an epidemic crisis of opioid analgesics abuse .
1.3 “Burnout” in primary health care
An article published in the British Journal of General Practice in December 2018 reviewed recent studies on labor shortage of primary health care in the United Kingdom and Europe. In addition, the author of this article interviewed some graduates from the British General Practice Training Program and identified the difficulty of hiring and retaining general practitioners in primary health care in the United Kingdom. These studies have shown that the increasing workload is an important reason for GPs to leave their jobs [5-7].
In a study published in Annuls of Family Medicine in January 2019, a survey of 740 GPs and personnel in San Francisco found that 53% of both clinicians and staff reporting burnout, and 30% of clinicians and 41% of staff no longer working in primary care in the same system 2 to 3 years later. It is statistically significant that burnout contributes to turnover among primary care physicians .
This is a vicious circle: the number of new doctors is decreasing and in-service doctors are leaving, while patients’ demand for medical services is increasing. As a result, doctors’ workload is increasing, which leads to GPs’ burnout, which in turn causes doctors to leave their jobs. This vicious circle is putting primary health care system in a state of “chronic blood loss”, losing a large number of GPs.
2. Tiki-taka tactics supported by community data
2.1 Community intervention and social prescription
In January 2019, Commissions from the Lancet journals published a report entitled The Global Syndemic of Obesity, Undernutrition, and Climate Change, which stated that “obesity is still increasing in prevalence in almost all countries and is an important risk factor for poor health and mortality. The current approach to obesity prevention is failing despite many piecemeal efforts, recommendations, and calls to action. The Commission urges a radical rethink of business models, food systems, civil society involvement, and national and international governance to address The Global Syndemic of Obesity, Undernutrition, and Climate Change” .
In the issue of British Journal of General Practice in December 2018, Professor Luke N. Allen et al. published an editorial entitled How to move from managing sick individuals to creating healthy communities. In this paper, the author pointed out that the future reform of the NHS was to strengthen the community intervention from GPs and to prevent the health risks of residents in communities through active intervention. The author cited the conclusion of another paper as the argument that people with “stronger relationships are associated with a 50% increased likelihood of survival than those with weaker social relationships”, and indicated that fast food, cheap alcoholic beverages, dangerous traffic, air pollution, expensive fruits and vegetables all contribute to the prevalence of chronic diseases. If uncontrolled, these factors will increase the number of visits, expenditure and work complexity in the local primary health care system.  Therefore, community-level prevention involves a localised approach to address the social determinants of health, including housing, living and working conditions, education, food, and social networks.
Another editorial, Social prescribing: where is the evidence? by Professor Kerryn Husk et al., published in the British Journal of General Practice in December 2018 affirmed the positive role of social prescription. Social prescribing, also known as community guidance, creates a formal means of enabling primary care services to refer patients with social, emotional or practical needs to a variety of holistic, local non-clinical services . The author indicated that even though there were still difficulties in research and lack of empirical evidence, social prescriptions have been applied by NHS and other institutions as an important means of social intervention for GPs to change from traditional medical intervention with the main purpose of prevention and chronic disease management to providing personalized care for patients’ physical and mental health. The authors believed that social prescriptions had great potential, especially for patients with complex health care and social health needs .
This is undoubtedly a positive and active way of thinking. If it can be implemented, then the main strategy of British NHS will change from “active defense” to “active attack”. In the context of soccer, traditionally, GPs are more likely to act as “midfielders”, the first line of defense after the “cause of disease” breaks into their own half-court, so as to reduce the number of “patients” entering the penalty area guarded by specialists. But in the new NHS tactics, the “halfway line” is about to move forward, and merge with the center line of public health prevention, or even the forward line of social prevention, and suppress the health risk in the attacking field. In this “Tiki-Taka” tactics (a popular Spanish football tactic, characterized by high defensive line, positional interchange among midfielders and extreme amount of possession), the powerful midfielders of general practice will undoubtedly become the most important tactical support.
2.2 The value of community data to Tiki-Taka tactics
To fully understand the social and community information is the prerequisite for GPs to realize the active intervention. In a commentary entitled Progress towards using community context with clinical data in primary care published in volume 7 of Family Medicine and Community Health in January 2019. Professor Heather Angier et al., after reviewing the current researches in this field, emphasized the incorporation of data on community-level factors into electronic health records (EHR). By doing so, doctors and researchers in the primary health care system could have more information sources, and more in-depth understanding of the clinical and non-clinical factors of the disease, so as to make more accurate clinical decisions, targeted interventions, and tailored treatments.
On this basis, the authors summarized the types of community data available at present, such as economic conditions, racial/ethnic characteristics and community environment of residential areas, and listed several primary health care studies that have used community data, for example, to monitor “community vital signs” and improve chronic disease management. They also stated that some potential positive impacts of community data, such as improvement of the relationship between primary health care system and community institutions, and locally-relevant clinical quality indicators. Finally, the authors emphasized that as this was an emerging research area, combining community data with EHR data may help primary health care optimize clinical care, target interventions, track population health, and strengthen community partnerships to reduce health disparities and improve health equity .
3. Responsibility of General Practice in the Future
Is it possible to address the current threats to primary health care by further integrating patients and society and advancing towards social causes? Maybe It is still a problem that needs the joint efforts and exploration of GPs all over the world. From Alma-Ata Declaration of 1978 to Astana Declaration of 2017, the theme of justice, equity and solidarity has always been the core idea［15］ in general practice. In October 2018, the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) held its 22nd World Conference of Family Doctors in Seoul, South Korea, with more than 2,000 family doctors and researchers from all over the world gathering together to show their commitment to the world by Seoul Declaration: “we commit ourselves as Family Doctors to play our full part in the implementation of the Astana Declaration. We have a passionate interest and a key role to play in the delivery of effective, competent, affordable and personalized primary health care”. In the final part of the Declaration, WONCA urged countries to invest in the training of skilled family doctors, training of all the members of the primary health care workforce, primary health care reform to aim for high quality and safe clinical services, and relevant research and new technologies that underpin high quality clinical care. Working conditions, including remuneration, must also be made attractive for family doctors and their teams .
There is still a long way to go to achieve these goals, but just as Professor Amanda Howe, the president of WONCA, said in an editorial of the Seoul Declaration in Family Medicine and Community Health, ” Actions speak louder than louds, but words are a start” . The development of general practice needs the joint efforts of general practitioners and researchers, which may change the primary health care industry and even the wider society in the end.
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