Dr Karen Price, President of the Royal Australian College of GPs (RACGP), presented a master class on primary care and the use of GIFs in public health communications last week at Croakey’s @WePublicHealth account, as fellow GP Dr Tim Senior observed:
Karen Price tweets:
“The 4 main features of primary care services: 1. First-contact access for each need; 2. Long-term person- (not disease) focused care; #. 3. Comprehensive care for most health needs; and 4. Co-ordinated care when it must be sought elsewhere.” How good is that? Starfield 2005
“The relationship between primary care physician supply and better health is not limited to studies in the USA. In England, the standardized mortality ratio for all-cause mortality at 15-64 years of age is lower in areas with a greater supply of GPs” (Starfield 2005). Really impressive.
“In addition to its relationship to better health outcomes, the supply of primary care physicians was associated with lower total $$ of health services. Areas with higher ratios of primary care physicians to population had much lower total health care $$ (costs)” (Starfield 2005).
How does this all happen? Well …Six mechanisms, alone and in combination, may account for the beneficial impact of primary care on population health.” Starfield 2005 These will follow…..
2. The contribution of primary care to the quality of clinical care. It’s High Quality Medical Care…
3. “The impact of primary care on prevention. The evidence strongly shows that it is in primary care that preventive interventions are best when they are not related to any one disease or organ system.” Starfield 2005 (Like I see every disease in general practice but I see the person first)
4. The impact of primary care on the early management of health problems (Starfield 2005). That means early early intervention. GPs save lives in an undramatic way.
5. The cumulative effect of the main primary care delivery characteristics (Starfield 2005). This is the longitudinal time frame which is so special about GP/Primary Care. We see you from cradle to forever and on. REAL therapeutic relationships. Over generations. It’s great!
6. The role of primary care in reducing unnecessary or inappropriate specialty care. Nearly all studies of specialist services concluded that there is either no effect or an adverse effect on major health outcomes from increasing the supply of specialists in the USA. (Starfield)
So that’s all for day one. Remember the basis of every good health system is a strong primary care sector. General Practitioners are a part of that and as a system we do 100% verifiable good work. The best there is. Even the @WHO agrees. Your GP is amazing — so don’t lose them!
Paradox of primary care
Last night I talked about the classic paper by Starfield. Showing all the benefits of a health system that is supported by a well resourced primary care sector. (As opposed to a skeletal framework). Tonight a quick look at another classic paper on the Paradox of Primary Care.
A key statement of this paper: “Efforts to improve the parts (evidence-based care of specific diseases) may not necessarily improve the whole (the health of people and populations).” This is a key philosophical concept for primary care versus hospital care
This paper is by Stange 2009 …HUH? “Quality of health care most commonly is measured by the application of disease-specific, evidence-based process-of-care guidelines. This evidence fairly consistently shows that Primary care deliver(s) poorer quality care than specialists.”
Yet … “In further contrast, ecological studies comparing states in the United States find that a greater supply of generalists and a lower supply of specialists is associated with greater quality of care on multiple disease-specific quality measures.” (Stange 2009)
This speaks to firstly the way we measure success as a single intervention on a single disease and the tyranny of the guidelines referenced by EBM guru Prof David Sacket BMJ 1996. Versus complex multimorbidity and multiple diseases…and yes too much medicine….
But we still need our hospital specialists, says Stange 2009. “Specialty care is especially important for those needing particular medical knowledge or procedural expertise”. The trick is an integrated system reducing hierarchy of funding — not a defunded Primary Care sector!
Seen from a patient’s point of view, that makes sense, right? GPs see everything: we prevent a lot, we diagnose most, we see the before, the during, and the after of everything and manage accordingly. In short we CO-ORDINATE care making sure patients don’t suffer OVERTREATMENT.
Stange 2009 says it all: “It is important to simultaneously understand and value quality of care at the level of specific illnesses, whole people, communities and populations.” So how we measure what we measure matters — which is an essential focus of understanding research paradigms.
So… I treat someone’s mental health as a priority over their disease end points of diabetes because I will get nowhere if I ignore depression, overeating & trauma to focus purely on HBa1c (although I juggle both). Mental health improvements mean their diabetes does too.
This is due to the bias of being able to understand what we can see. A simple before and after intervention instead of a whole system of health care and longitudinal time frames. But failing to see people as whole persons, or understand social inequity & bias to action costs money.
We like good simple and wrong. Stange 2009 sees it too. “It is easier to conceptualize and measure the value of specialism than of generalism. Specialism fits with the reductionistic understanding of disease and medical care that is dominant in Western countries.”
Stange: “Systems development is needed to integrate the complementary strengths of primary and specialty care to avoid unintended negative health and societal consequences from fragmenting efforts to improve the quality of health care.” Fragmenting care is bad for your health!
So philosophy and research are so important to understand the different ways we measure things to achieve very different but complementary results. Systems thinking is so important in some of those assumptions and I bang on about it everyday. GPs are the glue of the health system.
Finished for the night… Now you understand the Paradox of Primary Care by Stange 2009 and why the ridiculous hierarchy of health care and the associated disparity in funding needs to go go go….
Inverse care law
“An inverse care law persists in almost all low-income and middle-income countries, whereby socially disadvantaged people receive less, and lower-quality, health care despite having greater need.” Yep that makes no sense.
“Tudor Hart coined the term inverse care law (ICL)1 in 1971 to describe the double injustice that socially disadvantaged people not only tend to be more susceptible to illness than socially advantaged people but also receive less health care.'” This is from a paper (Cookson 2021).
There are “social inequalities: 1. in the ability to seek health care (eg by taking time off work, navigating complex systems, avoiding discrimination), 2. the ability to benefit from health care (eg by investing time and resources in following treatment regimens)…”
However, social inequalities in health-care quality and outcomes persist … 3. and the costs and risks of health care (eg due to multi-morbidity and medical workforce shortages). Australia’s GP see this with access to allied health, mental health and aged care.
A great paper by Richard Cookson, Tim Doran, Miqdad Asaria, Indrani Gupta, Fiorella Parra Mujica: The inverse care law re-examined: a global perspective, The Lancet, Volume 397, Issue 10276, 2021 Pages 828-838 Health economics is complicated and no GIF needed but many factors
So anyone who tells you health care reform is easy ..it ain’t. We look at health care as a separate part of our community but it is an integrated part. It includes employment, gender, geography, crime, crowding, pollution, medical workforce and ethnicity.
Australian GP and researcher @LizSturgiss had a trial to address this in Canberra (of all places) and published her results here (on GPs at the Deep End). Called the Deep End project, addressing issues of inverse care law with an Australian context.
There is now a community of Deep End practitioners still in Canberra but connected to other Deep End GPs around the world. A bulletin here. Noting burnout is a big issue for all GPs but especially those in areas of disadvantage but that’s for another day.
So it’s harder to work in areas of greatest health care need and it’s ALSO harder for people in those areas to access health care for a variety of complex reasons. And in Australia we have these pockets where all factors combine and the care received is inverse to the needs.
So now you know that primary care works well, that whole person care works better than fragmentation and no matter what — supplying health care includes not only access to health care workers and insurance schemes but is related to all policy. Those who have least suffer the most.
Health: “A state of complete physical, mental and social well-being and not merely the absence of. disease or infirmity.” WHO 1948 Is not easy when we look at inequity. We needed to know that. And now Good night again. Sleep well.
The need for joy and meaning
So the quadruple aim: 1. improving the individual experience of care; 2. improving the health of populations; 3. reducing per capita cost of healthcare. (Berwick) and THE FORGOTTEN 4. creating the conditions for the healthcare workforce to find joy and meaning in their work.
Glad you asked WHY. Because happy healthy Doctors are good Doctors. “Without joy and meaning in work, the workforce cannot perform at its potential.” (Sikka BMJ). It works for patient care…..
And clinical work is hard work. Have a look at the stats from the October 2013 Beyond Blue Survey. YIKES! Especially our youngest members. These are the three subscales of the Maslach Burnout Inventory.
According to the 2013 Beyond Blue survey, 70% of Doctors felt comfortable seeking help from family friends and partners but NOT from the workplace help schemes and around 25% would seek help from the Doctors advisory service.
Well maybe some of that is stigma? 12.7% thought Doctors with a history of depression or anxiety were not as reliable. 87% in the Beyond Blue survey thought Doctors had to present a healthy image……
On the other hand 52.5% thought confidentiality was a barrier to seeking help AND 27.5% thought there were concerns about career progression. So Doctors appear to fear stigmatising help seeking and the impact on their career. That’s not good for anyone.
Shanafelt 2017 presents the business case for investing in Physician wellness and burnout prevention. It matters for patient care & GPs need to be looked after by the system. 100% to look after patients which is what it is all about.
Shanafelt asks Q1. “In a time of limited resources and competing priorities, what’s the business case to address this issue?”. He notes “a lack of awareness regarding the economic costs of physician burnout. This uncertainty is typically expressed by (this) question.”
Q2.” This (physician burnout) is a national epidemic, what can we do about it?” Thus “the second barrier is uncertainty about whether anything can be done. This view is often expressed by the (above) fatalistic question.
Burned out physicians including GPs leave patient care “Multiple large, national studies of US physicians have indicated that burnout is one of the largest factors determining whether or not physicians intend to leave their current position over the next 24 months.”
Lots of studies suggest this intent for Doctors to leave practice due to burnout is real and I’ve heard it myself. “Studies demonstrate that physicians’ intent to leave correlates with actual departures” (Shanafelt 2017). This costs everyone but especially patients and the health system.
And it’s not just leaving the profession but burnout causes reduced productivity at work (Shanafelt 2017).
Further effects of physician burnout are on patients: 1. post discharge recovery time increases. 2. suboptimal prescribing and test ordering. 3. worse patient compliance as well as leaving practice and reduced productivity. Quadruple aim is important!
There is a key research finding in physician burnout: “Burnout is primarily a system-level problem driven by excess job demands and inadequate resources and support, not an individual problem triggered by personal limitations.”
That’s the best system. This recent year has demonstrated health is an investment. Ignoring that as an economic issue for all people is a fool’s errand.
‘Professor Sturmberg talks about complexity theory here There is a “(bureaucratic) worldview, however, (which) is unsuited for problem solving of real world VUCA (Volatility, uncertainty, complexity and ambiguity) problems.” https://ijhpm.com/MKmNZ/article_3783.html
A 2020 article: Sturmberg offers up a challenge in system design for the wicked problems of health systems needing both top down and bottom up. Plus, philosophic understanding of the difference between universal health care & primary health care concerns.
“Universal health care (UHC) is primarily a financing concern, whereas primary health care (PHC) is primarily concerned with providing the right care at the right time to achieve the best possible health outcomes for individuals & communities.” Sturmber: https://onlinelibrary.wiley.com/doi/abs/10.1111/jep.13395
So we have to be careful when looking at health systems to not think Good Simple and Wrong. To not think we can avoid the Quadruple aim. Nor can we avoid acknowledging the vast contribution of primary care or diminish its resources without altering everything else. FIN