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A smorgasbord of treats on primary care and related research

Introduction by Croakey: A broad definition of sustainability that included “maintaining a happy and healthy workforce across healthcare and academic sectors” informed the Society of Academic Primary Care conference, held earlier this month in Bristol, in England’s south-west.

Dr Tim Senior, a prominent GP and Croakey contributor, shares some of the conference discussions below, as part of his Churchill Fellowship investigating how to support GPs providing care in socioeconomically disadvantaged communities.


Tim Senior writes:

I’ve been thinking about the Society of Academic Primary Care conference in Bristol for a few days now. I was hoping to bring you a feast of primary care ideas all connected under the conference theme of Sustainable Primary Care.

However, the presentations I attended were so diverse, covering so many aspects of primary care and primary care research, that I can offer you something better than a feast.

I can offer you a smorgasbord.

Here is a buffet of disparate ideas, which I invite you to try, digest the ones you like, leave the ones you don’t.

There are common themes, and you’ll hear some of the thoughts these people provoked for me, but much of the benefit was in being reminded of the value and values of primary care, and in thinking how this might apply in our own work.

So, here’s a medley of ideas from the conference. If you don’t like one, another one will be along in a moment!

Relational continuity – primary care’s superpower

The importance of the relationship between patient and professional was a consistent theme through the conference.

The keynote from Professor Frances Mair, and Professor Victor Montori (who said via his video link “I’m not sure why you need a specialist at a GP conference”) looked at the centrality of relationships to healthcare. Helpful analogies and advice came thick and fast.

They emphasised the importance of care – “Healthcare without care is unsustainable.”

“When you talk about health, use the language of care, not the language of business,” Montori urged leaders and policymakers.

“We’ve moved to an ‘Industrial care’ model, which is about getting more people through the door, more widgets. This is cruel care. Treating patients as ‘parcels of care’ is not treating patients.”

Montori asked: “How do we judge effectiveness?”

“If our model is of fixing people and providing cures, then right treatment, right time, right place etc. makes sense. But with multimorbidity/chronic diseases, notions of right answer/right performance doesn’t make sense. Who is your paradigmatic patient when designing services?”

Time and again, Professors Mair and Montori pointed us toward relationship-based care – care that is caring. It provides for better health outcomes, and better experiences for patients and practitioners.

Elsewhere, Dr Kate Sidaway-Lee from the University of Exeter presented her research showing that people seeing their usual GP for an acute problem had fewer emergency department presentations on that day and in the following week and took longer to present back to the practice, compared with patients with similarly acute illnesses seeing a different GP or a locum GP.

In other words, seeing a regular GP for an acute illness did take the pressure off emergency departments, and also reduced demand for consultations in the same practice.

Interestingly, there has been a requirement in the GP contract to have a patient and public involvement (PPI) group.

The quality of these groups is variable, from highly effective and involved groups, to token representation that doesn’t have much influence.

Dr Emily Boam from Yorkshire and Humber region presented research showing practices in multiply deprived areas were less likely to have a functioning PPI group, but that this didn’t make a difference to practice rating by the Care Quality Commission.

We have no similar requirement in Australian general practice, though there are requirements in the Standards for General Practice for incorporating patient feedback.

However, the governance structures of Aboriginal Community Controlled Health Services go far beyond the model of PPI, and arguably are a mechanism for primary care to be much more accountable and responsive to community needs.

Sustainable presents and futures

Associate Professor Charlotte Blease, a philosopher and interdisciplinary health researcher from Uppsala University, gave an excellent, thought provoking keynote on the use of artificial intelligence (AI) in medical notes, in the context of increasing moves internationally for medical notes to be shared with patients – an initiative that hasn’t really taken off in Australia.

In among the current hype about AI, it was useful to be reminded from the start that they are “giant autocomplete devices” – AI doesn’t think for itself, but uses large language learning models to produce sentences that are plausible reconstructions in response to a stimulus.

Significant number of doctors already are using AI in some way – up to 30 percent are using it to help with differential diagnoses or to help to help write notes.

AI may be really helpful doing this, especially as medical records are adapted from being purely a clinicians aide-memoir to being a shared resource of clinical decision-making, and education.

Both patients and doctors are learning this new environment, and so naturally people will turn to AI to do this job. AI does it quite well. AI produces answers to clinical questions that appear much more empathic than answers from actual human doctors.

AI may be able to adapt and summarise notes separately for patients, families and health professionals.

However, AI is not without risks, and most notably for my work in Australia, it can embed cultural biases and racial discrimination into its outputs.

Artificial intelligence is coming to medicine and, in my view, we will have to become skilled users of it, as we would with other medical technologies, maximising the potential benefits, and mitigating the risks to protect patients.

One of the known problems that was touched upon was the environmental impact of the computer power needed to run AI. This was raised in the keynote, and the importance of understanding and minimising the health system’s environmental impact was highlighted in another important plenary session (see more on related issues in recent Croakey articles, here and here).

Photo by Dr Tim Senior

Climate advocacy lessons

Dr Tamsin Ellis and Professor David Pencheon gave an important joint keynote on sustainable primary care.

Pencheon was the founding Director of the Sustainable Development Unit for NHS England and Public Health England.

He spoke very clearly about the moral imperative for the health system and individuals working in the health system to act on climate change. As he spoke, he had tips on effective advocacy, and key statistics about the health system and its environmental impact.

“Pharmaceuticals are responsible for a large part of health service emissions because we throw so many of them away,” he said.

“Should we be mitigating or adapting? Don’t divide the two – the issue is blighted by this… Keep positive! Look for benefits now – and what’s the alternative?”

Pencheon highlighted the reach and influence of GPs.

“The footfall through general practice is huge, and GPs are trusted,” he said. “If we do nothing [on political action] that is incredibly dangerous.

“Change your bank [away from the big 4], think about where your money is invested and buy better food. Use your voice and your choice.

“Whatever your dream is, someone will be doing it. Find out how they did it, and take it to your own power-that-be.”

And on advocacy: “Don’t be a first rate physician and a second rate climate activist – climate is a health issue,” he said.

“Policy decisions are based on stories, and as GPs that’s our trade.

“To change the world, you need oratory and data – to hit head and heart. We’re not objective researchers, but emotional researchers with innate biases.”

Ellis brought her significant experience in designing and delivering training in the NHS on sustainability in health services.

A lot of the audience discussion was about large system issues and advocacy on policy needed to act on climate change.

Ellis shows that effective advocacy is accompanied by effective action. She has enabled practices to implement community gardens and walking groups.

The actions needed to reduce carbon emissions are the same actions needed for a healthy life – walk more, cycle more, drive less, eat less processed food, eat less meat.

Healthy takeaways

I hope there’s something you can take as a snack from this smorgasbord.

Primary care has core values of generalism and comprehensiveness, and so it’s almost inevitable that – in a discipline that has no referral criteria and deals with any problem presented – primary care research conferences can cover a wide range of topics.

Pick what matters to you!

Photo by Dr Tim Senior

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