Medical Education 1988, 22, 373-374

Editorial

‘If it hasn’t got a name, it doesn’t exist’: international classifications, primary care and education

‘Information systems and health statistics deal with data which have been ordered and have a name so that they can be counted. What has n o name cannot be counted and consequently has no impact. What has an incorrect or incomplete name leads when counted to irrelevant data pro- hibiting practical use or even a sensible inter- pretation.’ This provocative introduction to a significant devcloprnent in the field o f nosology of disease and health problemst opens up a num- ber of issues which could have far-reaching effects on quality of care, provision of resources and education, because classification is a key to knowledge.

Those who have worked with the successive versions of the International Classification of Disease (ICD), currently undergoing its loth revision, will know that what was (and still is) a useful tool has become somewhat blunted. Rea- sons for this are complex but include an absence oforganizing principles, and as the complexity of the instrument grew it tended to become an unstructured combination of chapters which had differing approaches to classification-anatomi- cal clinical, changing views of ‘causation’, clini- cal specialties and age groups. As its name indicates, it has remained a disease-oriented classification, and as such despite some of the shortcomings indicated it has served hospital practice well.

Unfortunately for medicine-outside-hospital, such a disease-based classification served primary care badly. Not only was some 50% of doctors’ work uncoded and uncodable (because it relates to people, and problems, often with the diagnos- tic disease label of little account) but what was

tlnrernational Closs$cation o/Primary Core. Edited by H. LAMBERTS & M. WOOD. Oxford University Press, Oxford, 1988. &rs.oo. ISBN: 1019 261633 I .

Correspondence: Professor J . D. E. Knox, Depart- ment of General Practice, University of Ihndee , Westgate Health Centre. Charleston I h v c , I h n d e e 11D2 4AD. UK.

coded was done with unnecessary difficulty because the rubrics available did not takc su f i - cicnt account of the nature and frequencies of disease processes encountered in general practice. In addition, few in general practice had sufficient time or training to capture data. The results of these and other factors are to be clearly seen even today in numerous official and otherwise well- written reports, critical to development of health services appropriately reactive to the changing needs of society. Thus the health care of children derives from hospital- and clinic-based disease statistics, and the care ofthe elderly is seen largely in terms of the institutionalized.

All the while the year 2000 looms nearer, the year by which all signatory countries to the Alma Ata Declaration (the UK among them) have pledged a population-based approach to the pro- vision of services so that there will be health care for all. The ccntral position of primary care to this philosophy was originally based on humanitarian principles, but the economic changes of retrenchment have done nothing to diminish but rather to enhance this centrality, because primary care is seen to play an efficient gate-keeping role for scarce and expensive hospi- tal resources-despite the paucity of data to sup- port this contention. Meantime, those concerned with general practice and health planning have not been idle. ‘I‘hc Royal College of General Practitioners carly on reacted to the inadequacies of the ICI) by producing a separate though com- patible classification-this so-called ‘College classification’-which, together with the pioneer work ofEimcrl Crombie and others, made possi- ble the UK National Morbidity Studies in general practice, of which there have been three so far. From such work it has become clear that adequate provision of health-care services, and professional development of such services, need systems of information much more closely rel- ated to reasons why people request and require

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3 74 Editorial

the services. the diagnoses, problems and mor- bidity involved, and processes of care provided. These were the stimulants leading to a number of developments: first, the publication of the Intcr- national Classification oftiealth Problems in Pri- mary Care and, latterly, the International Classification of Primary Care. This latest volume brings together in a simple manner all these complex issues, so that with appropriate training, all health-care personnel can capture and order data in a variety of modes-Reason for encounter, Procedural, Diagnostic and Coni- prehensive. The way is thus beginning to open to explore in ways not previously possible issues to do with quality of care and value for money.

But before this system contributes (;is it should) to the development of a better service and education based more firmly on the realities of patient care-general practice atid hospital- there will need to be created a generation which sees the importance of mastering a system which takes as much account of trivia as of major mor- bidity and learns how to capture the data and handle them. There are clear messages for those concerned to promote the academic discipline of general practice, for the discipline of community medicine, and, ultimately, for all doctors.

J . I>. F.. KNOX Dcpr.ttvien t qf Gcwernl I’racricc

CiiiiJersity qf Dundee