Patient centred primary health care

Below you will find the abstract for the talk on this topic as part of the International Seminar on Innovation in Primary Care.

Health extends well beyond the absence of disease or infirmity, which focuses solely on the negative range of the health spectrum. Disease based thinking, however, is a paradigm that has helped enormously in advancing medicine. It easily accommodated infectious health problems that had a clearly identified and simple etiology: there was a single cause for each problem and dealing with (curing!) the disease was basically an issue of dealing with responsible etiological agent. This continues today in the form of claims for the discovery of gens that are responsible for health conditions, for personality traits and even complex psychological functions. Progressively and unopposed, the idea crept in that health was just about ensuring that the heart worked, the lungs worked, the kidneys worked. And progressively the patients disappeared behind their conditions when not simply their organs.

Surely a straw man in our days? Unfortunately not. A prime example is at hand: the Quality and Outcomes Framework, the biggest initiative for pay for performance in the world, has provided General Practitioners in the UK with financial incentives for managing their patients. All clinical incentives in this framework are condition specific. The implicit assumption is that patients can be reduced safely and effectively to their blood pressure, their renal function, their cholesterol levels. And yet we know this is not the case.

We need to put the patient at the centre of the provision of health care. If philosophy, ethics or humanism are not good enough reasons for reversing this situation, perhaps we should be reminded that patients are responsible for their own care 24/7, that they know more about themselves (attitudes, behaviors, symptoms, compliance, incentives, preferences) that clinicians and health professionals will ever do, and, in the current economic climate, that if given the opportunity of making an informed decision, many patients will choose more conservative approaches than clinicians (and even forgo any treatment or diagnosis procedure) thereby simultaneously making substantive savings. 

International Seminar on Innovation in Primary Care

This Saturday (29 September 2012) we will organize an International Seminar on Innovation in Primary Care. These now well established annual event started in 2005 in Madrid, and this is the first one that will be conducted in the United Kingdom.

We are very proud to host this year's seminar, and we are very glad that we will be able to welcome international delegates, some of them also current members of the Brisbane Initiative. The topics for discussion will include: "The better value healthcare", "Health systems, primary care and efficiency of health services”, "Primary care services, use of technology and health needs", and “The contribution of Primary Care to Patient Centred Health Care Systems”.

We will post here the abstracts for these topics during this week.

Evidences Based Health Systems

There are a wealth of places where to look for information on how to build evidence based systems. We shall review four today that you my find useful as a first stop.

The Cochrane Database of Systematic Reviews offers very high standards of quality.  It includes a specific chapter on Effective Practice/Health Systems with a total of 112 items as at the time of writing this note, including 11 broad overviews.

Health Systems Evidence is a repository of evidence syntheses for the organization and delivery of health services. Registration is free and the information Although the interface is not as user friendly as promised in the website (most one pagers simply do not include a summary with the interpretation of the results), it works well as a repository of evidence.

The Health Evidence Network offers an online repository of evidence based information on Health Policy and Health Technology Assessment. It is a joint collaboration with the European Observatory of Health Systems and Policies.

Finally, International Health Care Comparisons is funded by the Department of Health and focuses on comparative analysis. It contains little information at present, but it makes the content quite easy to screen.

Building an efficient and responsive health system may be art. But there is also a lot of science to it, and these are a few places providing the building blocks.

Not just the physicians: nurses and midwives do also oppose the Bill

One may reasonably wonder who will have the upper hand in the end. If just a few days ago we had reviewed that the British Medical Association and the Royal College of General Practitioners were opposing the bill, now we have learnt that the Royal College of Nursing and the Royal College of Midwives. Although the secretary of Health has dismissed this last move as something actually more related to the issues of retirement pensions, the truth is that opposition is mounting.

Will he succeed in convincing an ever increasing front of health professionals opposing the reforms?

The NHS PROMs programme

Prof. Nick Black (London School of Tropical Medicine and Hygiene) gave last night an excellent update on the status of the Patient Reported Outcome Measures (PROMs) Programme in a seminar hosted by the Royal Statistical Society. The PROMs programme is a prospective collection of PROMs data before and after elective surgical interventions.

In a nutshell, the programme is in good health, with variable response rates, very reasonable for joint replacements (hip & knee), less so for varicose veins and groin hernias. The programme is being expanded in at least three different ways: additional interventions (coronary revsacularization), and pilots in relation to Primary Care and Long Term Conditions (LTC) and in Emergency care. Prof. Ray Fitzpatrick (Oxford) also provided some information on the current status of the LTC pilot.

Some questions from the floor focussing on sampling and representativeness issues were convincingly addressed by the speaker. There were also questions in relation to how to guarantee better linkage of PROMs data with other clinical information (e.g., Primary Care records).

The issue of how this information could be used for clinical management of individual patients was central to some comments, recognizing the potential impact of these measurements for clinical practice. This is exactly the focus of our programme of research on the use of individualized and standardized PROMs for improving Primary Care for people with multi-morbidity.

UK physicians reject the Health and Social Care Bill.

Christmas has not been benevolent to the Andrew Lansley's brainchild. Pressure is mounting on the , Health and Social Care Bill, now that the report stage – further line by line examination  - is about to be scheduled.

The British Medical Association, a voluntary association with over two-thirds of practising UK doctors in membership and an independent trade union, released in December a position statement "Why the BMA is opposing the whole Bill". The document calls for the "reform package as a whole" to be rethought. "It is not too late to think again. The Government’s reform approach is adversely affecting the ability of the health service to deal with the real priority of improving quality in the face of a massive financial challenge. This, rather than unnecessary and unwelcome restructuring, should be the priority."

Seven former presidents of the  Faculty of Public Health (FPH), the standard setting body for specialists in public health in the United Kingdom, have recently written to prime minister David Cameron to warn that the proposals will damage the public’s health and that ‘the package of changes proposed in the NHS Health and Social Care Bill will disrupt and destabilise the health service and exacerbate inequalities in the health of the population of England.’ An extraordinary General Meeting of the has been called by the end of the month to discuss the FPH's position.

GPs might be expected to show much more enthusiastic support for a Bill that would put them in the driver's seat of the NHS. But they clearly do not.

A recent online poll conducted by the Royal College of General Practitioners among its members on the support and actions to be taken in the relation to the Health and Social Care Bill has included 2,625 self selected members from a membership of over 44,000 (about 7%). With this limitations in mind, the results show that about 5 out of 10 of the participants "strongly" support to seek the withdrawal of the bill, while about other 3 out of 10 would support it. and it did not really make much of difference whether this should be done in isolation (93%) or as part of a joint effort with other Colleges (98%).

If the bill is finally passed in its current format, the opposition of the very professionals that will have responsibility for its implementing casts serious doubts that it may achieve the stated objectives.