Public health in general practice

Steve Gillam 02.11.10

Outline

 What do we mean by PH in PC  Models of primary care  Educational challenges  Commissioning and other eastern foibles  Research agenda

1. Defining the role  Distinguished from biomedical and

humanist traditions  Derive from ‘fundamentals’: registered

list, generalist role, referral rights(gatekeeping)

 Delivered by different disciplines  Historically ‘oppositional’

Preventive interventions

 Primary  Health education, behaviour change,

immunisation, welfare benefits advice, community development

 Secondary  Opportunistic detection of chronic disease,

screening  Tertiary

 Chronic disease management

High risk individual and population based strategies for prevention (Rose)

Identify and treat those beyond a threshold for risk factor

Shift the whole population distribution of risk factor

2. Defining the model

Public Health Package

Package Package Elements Cost/person/year

(CMH) (USS, 1990)

Expanded programme on immunization, school health ( including deworming), micronutrient supplementation, health education, nutrition, family planning, tobacco and alcohol control, disease surveillance, vector control, aids prevention

Short course (DOTS) tuberculosis treatment ($0.6), management of the sick child ($1.6), prenatal and delivery care ($3.8), family planning and sexually transmitted diseases treatment ($1.1), limited care for other ailments ($0.7)

Total $12

$4.2

$7.8 Minimum essential clinical services

QOF Health gains   Real but modest gains in some areas, e.g. asthma, DM

  No definite improvement in CHD related to QOF

  Better recording in QOF but not untargeted areas

  No improvement in outcomes, except possibly epilepsy

N Engl J Med 2009;361:368-78.

Population health and equity   Inequalities related to deprivation slowly narrowing

  Reductions in age-related differences for CVD/diabetes

  Variable effects for e.g. gender related differences in CHD

Dixon, Khachatryan & Boyce. The public health impact, In Gillam & Siriwardena (eds) The Quality and Outcomes Framework, Radcliffe, Oxford 2010.

Lancet 2008; 372: 728–36

QOF scores nationally (% total points) and changes in exception reporting rates 2004-2009

QOF balance sheet   Improved data recording and analysis

  Modest health benefits for individuals and populations

  Narrowing of inequalities in processes of health care

  Opportunity costs contested

  Unintended consequences: on workforce, professionalism, ‘McDonaldisation’

  Re-defined meaning of quality

  Tyranny of evidence

Community Oriented Primary Care

“The community general practitioner...” Julian Tudor Hart. A new kind of doctor. London, Merlin Press 1988.

3. nMRCGP curriculum statement

  GPs have a responsibility for the community in which they work, which extends beyond the consultation with an individual patient. The work of family doctors is determined by the makeup of the community and therefore they must understand the potentials and limitations of the community in which they work and its character in terms of socio-economic and health features. The GP is in a position to consider many of the issues and how they interrelate, and the importance of this within the community. In all societies healthcare systems are being rationed, and doctors are being involved in the rationing decisions; they have an ethical and moral duty to influence health policy in the community.

Capacity building

 Overcoming obstacles  Political/ideological  Contractual  Undergraduate training  PH in the nMRCGP  Organisational turbulence  QOF and the biomedical model

 New models of training

Examples of PH related skills

 Health needs assessment  Technology/options appraisal  Evidence based health care  Data interpretation  Audit  Health services evaluation  Strategic development/planning

4. Genealogy of PCBC   GP Fundholding   Total purchasing

  Locality purchasing

  Primary Care Groups

  Primary Care Trusts

  Practice Based Commissioning

Stages in evolution/development of PBC

NHS structure - new

Three domains of Public Health

5. The research agenda

Primary care-oriented systems are associated with

 More preventive interventions  Better health outcomes  Greater patient satisfaction  Reduced costs of health care  Reduced use of secondary sector

Research priorities

  Practice-based research, e.g. meaning of symptoms, continuity, MUPS, etc

  Population health impact of different models of PHC

  Educational research in PH/PC   Planning/service development role   Policy research – impact of new white papers

Summary

  Public health roles in general practice: preventive and managerial

  Obstacles to be overcome in realising the GP/PH role

  Implications for GP training   New models of primary care delivery will emerge   Multifaceted research agenda