Primary Health Care: Theory and Practice PDF

Primary Health Care THEORY AND PRACTICE Trisha Greenhalgh Department of Primary Care and Population Sciences University College London UK Primary Health Care THEORY AND PRACTICE To my students, who expected me to write this book. Primary Health Care THEORY AND PRACTICE Trisha Greenhalgh Department of Primary Care and Population Sciences University College London UK C 2007 Trisha Greenhalgh Published by Blackwell Publishing BMJ Books is an imprint of the BMJ Publishing Group Limited, used under licence Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia The right of the Author to be identiﬁed as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First published 2007 1 2007 Library of Congress Cataloging-in-Publication Data Greenhalgh, Trisha. Primary health care : from academic foundations to contemporary practice / Trisha Greenhalgh. p. ; cm. “BMJ books.’’ Includes bibliographical references and index. ISBN 978-0-7279-1785-0 (pbk. : alk. paper) 1. Primary care (Medicine) I. Title. [DNLM: 1. Primary Health Care. 2. Health Services Research. W 84.6 G813p 2007] RA427.9.G74 2007 362.1–dc22 2007003618 ISBN: 978-0-7279-1785-0 A catalogue record for this title is available from the British Library Set in 9.5/12pt Palatino by Aptara Inc., New Delhi, India Printed and bound in Singapore by COS Printers Pte Ltd. 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The author and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this book. Contents Acknowledgements, ix Preface, xi Foreword, xvii 1 Introduction, 1 1.1 What is primary (health) care?, 1 1.2 What is academic study?, 13 1.3 What are theories – and why do we need them?, 19 2 The ‘ologies’ (underpinning academic disciplines) of primary health care, 23 2.1 Biomedical sciences, 24 2.2 Epidemiology, 26 2.3 Psychology, 32 2.4 Sociology, 34 2.5 Anthropology, 36 2.6 Literary theory, 41 2.7 Philosophy and ethics, 43 2.8 Pedagogy, 50 3 Research methods for primary health care, 57 3.1 What is good research in primary health care?, 58 3.2 Qualitative research, 63 3.3 Quantitative research, 66 3.4 Questionnaire research, 72 3.5 Participatory (‘action’) research, 74 3.6 Research data – and analysing it, 75 3.7 Critical appraisal of published research papers, 80 3.8 Systematic review, 83 3.9 Multi-level approaches to primary care problems, 85 4 The person who is ill, 90 4.1 The sick role, 91 4.2 The illness narrative, 94 4.3 Lifestyle choices and ‘changing behaviour’, 98 4.4 Self-management, 102 4.5 Health literacy, 108 v vi Contents 5 The primary care clinician, 115 5.1 The role of the generalist, 116 5.2 Clinical method I: rationalism and Bayes’ theorem, 118 5.3 Clinical method II: humanism and intuition, 124 5.4 Clinical method III: the patient-centred method, 129 5.5 Inﬂuencing clinicians’ behaviour, 133 5.6 The ‘good’ clinician, 137 6 The clinical interaction, 146 6.1 The clinical interaction I: a psychological perspective, 147 6.2 The clinical interaction II: a sociolinguistic perspective, 151 6.3 The clinical interaction III: a psychodynamic perspective, 156 6.4 The clinical interaction IV: a literary perspective, 160 6.5 The interpreted consultation, 164 7 The family – or lack of one, 175 7.1 Family structure in the late modern world, 176 7.2 The mother–child relationship (or will any signiﬁcant other do these days?), 185 7.3 Illness in the family – nature, nurture and culture, 191 7.4 Homelessness, 194 8 The population, 202 8.1 Describing disease in populations, 202 8.2 Explaining the ‘causes’ of disease, 204 8.3 Detecting disease in populations, 209 8.4 ‘Risk’: an epidemiological can of worms?, 216 9 The community, 225 9.1 Unpacking health inequalities I: deprivation, 225 9.2 Unpacking health inequalities II: social networks and social capital, 229 9.3 Unpacking health inequalities III: life course epidemiology and ‘risk regulators’, 232 9.4 Developing healthy communities I: community oriented primary care, 237 9.5 Developing healthy communities II: participatory approaches, 240 10 Complex problems in a complex system, 248 10.1 Illness in the twenty-ﬁrst century: chronicity, comorbidity and the need for coordination, 248 10.2 Coordinating care across professional and organisational boundaries, 254 Contents vii 10.3 The electronic patient record: a road map for seamless care?, 258 10.4 The end of an era?, 263 11 Quality, 273 11.1 Deﬁning and measuring quality, 274 11.2 A rational biomedical perspective: evidence-based targets, planned change and criterion-based audit, 279 11.3 A narrative perspective: signiﬁcant event audit, 282 11.4 A social learning perspective: peer review groups and quality circles, 287 11.5 A phenomenological perspective: the patient as mystery shopper, 290 11.6 A sociological perspective: Quality Team Development as organisational sensemaking, 293 Index, 305 Acknowledgements This book is my own work, and I alone take responsibility for errors and omis- sions. It would not have been possible for me to tackle the vast ﬁeld of primary health care without inspiration, insights and contributions from dozens if not hundreds of academic and clinical colleagues. Many of these people are men- tioned by name in the sections of this book where their input has been direct, explicit and auditable. But I am also indebted to the numerous colleagues and students who have provided more subtle, indirect and diffuse input to my knowledge and understanding of primary health care over the years. They are, quite literally, too numerous to list in full. I hesitate to single out any individual or group for special mention because my debt to the academic community is so extensive, but I must acknowledge in particular my outstanding team of tutors on the online MSc in International Primary Health Care at University College London, with whom it is a privilege and a joy to work. Thanks also to Mary Banks and her team at Blackwell Publishing for the unrivalled quality of their support in taking this book from an idea on the back of an envelope to the ﬁnished product. They have seen the work go through many metamorphoses. And ﬁnally, to my long-suffering husband Fraser Macfarlane and sons Rob and Al for their forbearance, patience and support as the magnum opus slowly took shape. ix Preface In 1999, the editor of the Lancet, Dr Richard Horton, threw down this gauntlet: ‘Primary care is the subject of more charters, declarations, manifestos, and principles than any other medical discipline, except perhaps its similarly plagued cousin, public health. Yet this efﬂux of ruminations from worthy experts and respected bureaucracies has contributed hardly anything to the daily practice of family medicine’.1 Horton’s words were met with outrage from primary care academics world- wide, and I certainly shared that outrage. But his editorial revealed two impor- tant things. First, that the academic foundations of primary care, if not weakly developed in themselves (and perhaps they were), had been poorly articulated by academics within our discipline. Second, that these foundations were, as a result, widely and profoundly misunderstood by people in powerful positions in academia and medical publishing. It was Horton’s shot across the bows that prompted me to take on the task of producing a completely new, single-author textbook on the academic basis of primary health care. The case for such a book was not difﬁcult to make. Remarkably few aca- demic textbooks in this ﬁeld have ever been written – and to my knowledge, no new ﬁrst editions have been published in the past 15 years. The giants on whose shoulders I stand include Britain’s William Pickles (Epidemiology in Country Practice, originally published in 19392 ) and Julian Tudor Hart (A New Kind of Doctor, 19883 ); Hungary’s émigré to Britain Michael Balint (The Doctor, His Patient and the Illness, 19564 ); America’s Barbara Starﬁeld (Primary Care, 19925 ) and Robert Rakel (Textbook of Family Medicine, 19736 ) and Canada’s Ian McWhinney (A Textbook of Family Medicine, 19867 ).∗ I have also been inspired by Gillian Hampson’s excellent textbook for nurses, Practice Nurse Handbook, ﬁrst published as Bolden and Tackle’s Handbook in 1980.9 Apart from more up-to-date reference lists, what does this book offer that goes beyond what the greats of a generation ago came up with? First and ∗Ishould also mention John Noble and team’s Primary Care Medicine, the leading US textbook, which is an excellent overview of the clinical problems seen in primary care practice, along with a guide to evidence-based decision making.8 This is an outstanding reference tome for doctors in clinical practice, but does not attempt to cover the breadth of interdisciplinary territory addressed here. Another comprehensive textbook written for a US audience is Rakel’s Textbook of Family Medicine, ﬁrst published in 1973 and now in its 7th edition.6 While mainly centring on clinical problems, it includes sections on evidence-based medicine and also covers the important work of McWhinney. xi xii Preface foremost, I have deliberately devoted a large section of the book to disentan- gling the diverse disciplinary roots of primary health care. Pickles, Fry and Starﬁeld took an almost exclusively epidemiological perspective and showed how such a perspective could both emerge from and serve to inform the work of the primary care team. Balint focused on the psychodynamic perspective and showed how this could illuminate the study of the doctor–patient relationship. Tudor Hart linked epidemiology with political science and drew links between social inequalities and health outcomes. McWhinney, to whom I owe a partic- ular intellectual debt,† drew on a range of disciplines including epidemiology, psychology and moral philosophy, but did so in a way that produced a uniﬁed, multi-level theory (patient-centred medicine; see Section 5.4) rather than – as I have chosen to do – setting out a menu of different disciplinary and theoret- ical perspectives as possible ‘options’ for cutting the cake of primary care. It is on McWhinney’s important early work, and with the advantage of the last decade in which primary care has matured considerably as an academic ﬁeld in its own right, that I seek to build. I have called Chapter 2 ‘The “ologies’’ of Primary Health Care’ because I believe that no single ‘ology’ (be it basic biomedical science, epidemiology, psychology, sociology, anthropology or philosophy) can alone underpin either practice or research in primary care. What is needed is not a single, ‘minestrone’ discipline that primary care can call its own, but a greater recognition by prac- titioners and researchers that different primary disciplines provide different theoretical lenses through which the complex and multifaceted problems of primary care can be studied. As I explain in Chapter 2, identifying the right ‘ology’ for a particular primary care problem is one of the key skills of the academic practitioner. The second unique feature of this book is that it is (to my knowledge) the ﬁrst general, single-author academic textbook to take an explicitly multi- professional perspective on primary health care (as opposed to general prac- tice or family medicine). The shift from uniprofessional to multi-professional focus reﬂects changes in the organisation of primary care over the past 20 years and in the diverse roles associated with its delivery – particularly the growth of primary care nursing. It also reﬂects, I guess, the increasing role of the person who is ill in his or her own care, since the ‘expert pa- tient’ (see Section 4.4) is also a member of the multi-professional team. Only around half the students on my MSc course in International Primary Health Care (www.internationalprimaryhealthcare.org) are medically qualiﬁed; the remainder have backgrounds in nursing, health policy, pharmacy, social work, physiotherapy and management. As I emphasise in Chapter 10, illness in the † That is not to say that I regard the contribution of the other authors listed here as less intellectually signiﬁcant, but that my own take on academic primary care aligns most closely to that of McWhinney and his team. Preface xiii twenty-ﬁrst century is characterised by complexity, comorbidity and the need for coordination. In this context, textbooks aimed exclusively at a single pro- fessional group are increasingly anachronistic. The third unique selling point of this book is that every word has been written by a single author. There is a touch of irony here. If primary care is so intellectually diverse, so clinically and organisationally complex and its practice necessarily multi-professional, surely it would be better to include an appropriate range of individuals as chapter authors, each of whom would cover a particular area of expertise. There are certainly some advantages to such an approach – for one thing, the subject matter would be covered more evenly and comprehensively. As it is, this textbook is biased towards my own areas of interest and expertise (sociological aspects of illness and healthcare, ethnic health, electronic records) and somewhat superﬁcial on other areas (such as epidemiological databases). But the upside is – I hope – that this book offers a holistic overview of the ﬁeld along with consistency of style that simply cannot be achieved in a multi-author textbook. Incidentally, a massive, multi-author reference textbook on primary health care has recently been published in the UK,10 and an equally weighty European Textbook of Family Medicine has recently rolled off the press. I do not seek to compete directly with these tomes, but to supplement them with one woman’s take on the parameters of our discipline. Having said that, I make no claim to comprehensiveness. In a ﬁeld as diverse and rapidly changing as primary health care, any attempt at encyclopaedic coverage of its multitudinous themes in a single volume is doomed to failure, and in any case the academic journals make a much better job of covering all the latest topics. Like McWhinney before me, I have sought to produce a ‘territory map’ of academic primary care along with some illustrative examples of how theory and method may be applied to the huge range of potential research topics. Though necessarily incomplete and distorted by my personal interests and prejudices, I hope this map will prove sufﬁciently coherent to convey the breadth of what counts as the ‘normal science’ of academic primary health care and sufﬁciently ﬂexible to accommodate perspectives and theories that I have missed (or which are yet to emerge). What, then, is my intended audience for this book? To paraphrase John Van Maanen, any book that aspires to the status of academic work has three potential audiences:11 1 Scholars in the ﬁeld. This book is written primarily for people who are al- ready working as academics in primary health care or who aspire to enter the ﬁeld as researchers or teachers. These are the people who, by and large, see the subject matter of primary health care through similar eyes to mine, who already know (or are learning) the jargon, who share (or are coming to share) the assumptions and are familiar with the main theories and methods used in primary care research. Included in this group are students (PhD, MSc and ambitious undergraduates) who seek to deﬁne, with a view to extending, the margins of knowledge in primary care. xiv Preface 2 Thinking practitioners. This book is also intended for general practitioners, practice and community nurses, and other primary care professionals who wish – for personal fulﬁlment or career progression – to go beyond the mul- titude of books on the shelves that promise ‘ten tips for better consulting’ or ‘how to organise your practice.’ The examination for the Membership of the Royal College of General Practitioners (www.rcgp.org) now includes an under- standing of research and the academic basis of general practice in its syllabus. But be warned: I did not set out to write a textbook for the Membership of the Royal College of General Practitioners, nor have I consulted or collaborated with its Board of Examiners, so do not take my word for what will come up in the exam or what the ‘right’ answers will be deemed to be. 3 General readers. Finally, this book is intended for people – especially in other academic disciplines – who have not the faintest idea what primary health care is and have even less clue about its academic basis. Primary health care is (like education, human resource management and in-ﬂight catering) an applied ﬁeld of study. Its main subject matter is not a unique set of abstract premises and theories nor a set of observations made in the pure environ- ment of the laboratory, but the messy reality of the real world with all its complexity and situational contingencies. As the opening quote of this Pref- ace illustrates, the academic basis for applied ﬁelds is harder for outsiders to grasp, not least because so many practitioners within those ﬁelds are unclear about the concepts and theories that inform (often implicitly) the work that they do. It follows that those of us who hold tenured professorships in ap- plied ﬁelds must spend at least some of our Sunday afternoons setting out our stall in a way that academics from the traditional ‘ologies’ can begin to take this seriously. I hope that, in this book, I have begun to address that task. One ﬁnal comment about the intended audience for this book: I live and work in the UK, and many (though by no means all) of my examples are taken from my own direct experience. This means that this book will perhaps be more meaningful to readers who are based in the UK. But this book is also intended as the course textbook in an international Masters course that takes students from (so far) four continents and 17 different countries. Whilst I use local examples at both micro level (e.g. the primary care consultation as it generally happens in the UK) and macro level (UK health policy or funding arrangements), I have presented these as examples, and have deliberately tried to select ones that provide transferable insights for students from other countries. I hope, therefore, that this book will prove useful to an international audience, and I would be especially keen to receive suggestions for meeting the needs of this wider audience should the book run (dare I say it) to a second edition. Trisha Greenhalgh OBE University College London March 2007 Preface xv References 1 Horton R. Evidence and primary care. Lancet 1999;353:609–610. 2 Pickles W. Epidemiology in Country Practice. Bristol: John Wright; 1939. 3 Hart JT. A New Kind of Doctor. London: Merlin Press; 1988. 4 Balint M. The Doctor, His Patient and the Illness. London: Routledge; 1956. 5 Starﬁeld B. Primary Care: Balancing Health Needs, Services and Technology. New York: Oxford University Press; 1992. 6 Rakel R. Textbook of Family Medicine. 1st edn. New York: Elsevir; 1973. 7 McWhinney IR. A Textbook of Family Medicine. 1st edn. Oxford: Oxford University Press; 1986. 8 Noble JH, Greene HL, Levinson W, et al. Textbook of Primary Care Medicine. 3rd edn. New York: Mosby; 2000. 9 Hampson G. Practice Nurse Handbook. 5th edn. Oxford: Blackwell; 2006. 10 Jones R, Grol R, Britten N, et al. Oxford Textbook of Primary Medical Care. Oxford: Oxford University Press; 2004. 11 Van Maanen J. Tales of the Field: On Writing Ethnography. Chicago, IL: University of Chicago Press; 1986. Foreword In 1974, as a working GP in what was then still a functioning colliery village, I was invited to lecture on primary care at Johns Hopkins University Hospi- tal in Baltimore. This was an awesome responsibility. Johns Hopkins was the place where Sir William Osler and William Henry Welch added Rockefeller’s oil fortune to German laboratory science, thus realising in practice Abraham Flexner’s dream of medical education founded on hospital specialism and sci- entiﬁc evidence.1 This set a world gold standard pattern for medical education which even today remains largely intact. True, I was only invited by the Department of Public Health, which, though distinguished in its own right, was still considered by all other faculties as only a minor adjunct to clinical medicine and surgery. And of course there was no department at all for general practice, family medicine, or any other concept of primary health care. However, the phrase “primary care’’ itself had suddenly become fashionable. Kerr L. White, then at Chapel Hill, North Carolina, had shown that in one average month, out of 1000 adult US citizens at risk, 750 had some sort of illness, 250 consulted any sort of doctor, 9 were admitted to any sort of hospital, and only 1 actually reached a teaching hospital to provide case-material for learning. He originally got this idea from John and Elizabeth Horder’s referral data, from the James Wigg practice in Kentish Town.2 Con- sultants in teaching hospitals ignored at their peril mounting evidence that existence of cost-effective generalists was a precondition for their own sur- vival as real specialists, rather than “specialoids’’ – doctors claiming specialist fees but without effective hospital support. That useful term was coined by John Fry3 , one of the ﬁrst to recognise this truth. It was conﬁrmed by a report from the American College of Cardiology, which found that though in Boston, Miami and New York there were more than 10 cardiologists per 100,000 popu- lation, 70% of these had ofﬁce-based rather than hospital-based practices, and half were not specialist Board-certiﬁed.4 In a market economy, health workers closest to technology make the most money, and nobody wants either to be a generalist, or to provide continuing care. So before my lecture I was shown around Johns Hopkins Hospital. Like most large hospitals, its ground ﬂoor was built around an exhausting and apparently endless corridor, with a network of pipes and cables running along its ceiling. As we approached somewhere about halfway along this corridor I saw a roughly cut cardboard sign hanging from bits of string looped around the pipes. And this is what it said: DEPARTMENT OF PRIMARY CARE → xvii xviii Foreword My guide was intrigued – he had never noticed it before. We followed the arrow, and found ourselves in the Emergency Room. It was heaving with the sort of events one sees on television doctordramas – children with acute severe asthma whose parents had never been told the difference between a ’preventer’ and ’reliever’; diabetic patients in ketoacidosis whose medication had not been reviewed for years; overweight men rigid with low back pain who had never received advice or physiotherapy; elderly people whose undetected hypertension had led to a massive stroke; and smokers whose unchecked habit had ﬁnally caused them to cough up blood. These everyday ‘emergencies’ would occur very rarely in a country with a developed primary care system accessible to the whole population. The barbarism of the scene was conﬁrmed by the presence of several heavily armed policemen. The doctors and nurses conﬁrmed that their work had indeed just been renamed, in tune with fashion. New words, unchanged resources. I tell this story ﬁrst to establish two points, and then to draw an important conclusion for the many thousands of students who will use this book, in this ﬁrst edition and the many others which surely will follow. First, even in the USA, things have moved on since then, as is the nature of market economies. Specialoids have not been eliminated, but they have been pushed back – by the mighty force of corporate investors in health care, whose proﬁts depend on rationalising the processes of commodity production, and have no interest in maximising doctors’ incomes. So things get rapidly better, and even if people get worse, more and more things can be done to repair them. In Britain, where until 1979 the National Health Service, and the medical schools producing its doctors, all operated as a gift economy outside and above the market, both things (medical and nursing knowledge and resources) and people (staff and patients) steadily improved, even though both service and teaching functions were always grossly under-resourced. In USA in the early 1980s, one single department of family medicine in Worcester, Massachusetts, employed more staff than all the UK departments of primary care and general practice put together. Our health professionals learned how to listen and talk to patients as if they were friends, neither customers to be ﬂattered nor sheep to be herded. Among their most impressive teachers was Trish Greenhalgh, in her frequent columns in the British Medical Journal. More than any other medical journalist, she spoke to her fellow GPs in the language of experience, but never without linking this to our expanding knowledge from the whole of human science. When I compare the outlines of primary care so lucidly presented in this wonderful book, obviously derived from rich experience of real teaching and learning, with the grand guignol theatre of London medical schools when I was a student 1947–52, the advance is stunning. Young health workers today are incomparably better educated than they were in my immediately postwar gen- eration, and from what I see of mature students entering medicine at Swansea Clinical School, they are now moving ahead faster than ever before. They know more of what really matters, the body of knowledge from which they draw is larger, simpler, and much more effective, and their attitudes to patients are hugely more sensitive and better informed. Foreword xix But here we reach my second point. Students in every advanced economy now face an imminent future in which technology will certainly go on improv- ing, but human relationships are rapidly getting worse. In 1996, even before we got incontrovertible evidence of approaching environmental crisis, the United Nations report on human development showed that the world then contained 358 people with one billion or more US dollars. Their total wealth equalled the combined incomes of the poorest 45% of the world population.5 Dispro- portionate wealth on this scale creates equally disproportionate power. Health care systems in almost all countries, whatever their stage in economic develop- ment, have been conscripted to a single market-oriented pattern determined by the World Bank, which now has a far bigger health budget than the United Nations’ World Health Organization. Students of anatomy will not ﬁnd what has become the most potent of all human organs, the wallet. The market decides. Even if all these 358 billionaires were angels, determined to address the needs of all people rather than such wants as are proﬁtable, they must maximise their cash returns on investment. If they do not, their corporations will be devoured by competitors. So the irresistible force of advancing scientiﬁc knowledge collides with the immovable object of a global economy in which meeting global needs is al- lowed to proceed only as a byproduct of making very rich people richer still.6 They say our world began with a big bang. Unless your generation recognises the difference between natural laws, which cannot be changed, and human laws (including those of economics) which arise from human decisions and behaviour, that may be how it will end. Students today will have to learn, and later to apply their learning, within contexts of crisis no less profound than that from which my generation only just managed to emerge in 1945. Some of the social relationships already established in the pre-“reform’’ NHS, which were a precondition for developing the ideas and practice outlined in this book, could still provide foundations for rebirth of the honesty and hope we now desperately need. Julian Tudor Hart References 1 Berliner HS. A larger perspective on the Flexner report. Int J Health Serv 1975;5:573–592. 2 White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885–892. He acknowledged his debt to the Horders in White KL, Frenk J, Ordoñez C, Paganini JM, Starﬁeld B (eds). Health Services Research: An Anthology, Vol. 534. Pan Amer- ican Health Organization Scientiﬁc Publication; 1992:217–226. 3 Fry J. Medicine in Three Societies: A Comparison of Medical Care in the USSR, USA and UK. Aylesbury, Bucks: MTP; 1969. 4 Lancet 1974;i:617. 5 Jolly R (ed.). United Nations Report on Human Development, 1996. 6 Hart JT. The Political Economy of Health Care: A Clinical Perspective. Bristol: Policy Press, 2006. CHAPTER 1 Introduction Summary points 1 Primary health care has many deﬁnitions. Most of them include the follow- ing dimensions: ﬁrst-contact care; undifferentiated by age, gender or disease; continuity over time; coordinated within and across sectors; and with a focus on both the individual and the population/community. 2 In the twenty-ﬁrst century, traditional academic skills (the ability to think logically, argue coherently, judge dispassionately and solve problems cre- atively) must be supplemented by contemporary academic skills (communi- cation, interdisciplinary teamwork, knowledge management and adaptability to change). 3 Primary care is an applied (secondary) discipline and its study is problem- oriented. It does not have a discrete scientiﬁc paradigm to call its own. Rather, it draws eclectically on a range of underpinning primary disciplines (which will be discussed further in Chapter 2). 4 Different problems in primary care require different perspectives, based on different conceptual and theoretical models. It will never be possible to come up with a single ‘unifying theory’ that explains all aspects of primary care. Studying different theories can help illuminate why different people look at (and try to solve) the ‘same’ primary care problem in different ways. 5 There is a tension between the typical ‘textbook deﬁnition’ of primary care (concerned with a tidy disease taxonomy, evidence-based treatments and a compliant patient in a stable family and social context) and its practical day-to- day reality (fragmented and changing populations, unclassiﬁable symptoms, absent or ambiguous evidence and mismatch of goals and values between clinician and patient). The academic study of primary care should not focus on the former at the expense of the latter. 1.1 What is primary (health) care? We hear increasingly of a ‘primary care led health service’, ‘primary care based research’, ‘capacity building in primary care’ and ‘primary care focus’ for healthcare planning. But when we talk about primary (health) care, what exactly do we mean? Is primary care anything that occurs outside a hospital? What about a hospital-based walk-in service for minor illnesses? Is voluntary sector care (such as that provided by self-help charities) part of primary care? If a general practitioner (GP) or family doctor (or a general internist in the 1 2 Chapter 1 USA) provides specialist services, does that still count as ‘primary’ care? And, frankly, does it matter? Instead of chasing a tight deﬁnition of primary care and enforcing it across all countries and healthcare systems, would we be better off with ﬂexible parameters that can be applied with judgement in different contexts? Let’s start with a working deﬁnition and see how it stands up to closer scrutiny. Primary health care is what happens when someone who is ill (or who thinks he or she is ill or who wants to avoid getting ill) consults a health professional in a community setting for advice, tests, treatment or referral to specialist care. An obvious primary care contact is a visit to the general medical practitioner or GP (referred to in some countries as the family practitioner or family doctor),∗ for example, with an episode of acute illness, for ongoing care of a long-term health problem or for a check-up or screening test. But primary care in the UK – and in many other countries – also includes pharmacy services, community- based nursing services, optometry and dental care. It includes not merely the acute care that sick persons might receive before they enter hospital with a serious illness (such as a stroke or diabetic emergency), but also the care they receive after discharge – rehabilitation, ongoing education and support, and continuing surveillance of their chronic condition. Until about 1980, the focus of most writing about primary care was the work of the individual GP in treating and preventing illness. Take, for example the following deﬁnition produced by the Leeuwenhorst working party in 1974: ‘The general practitioner is a licensed medical graduate who gives care to individuals, irrespective of age, sex, and illness. He will attend his patients in his consulting room and in their homes and sometimes in a clinic or hospital. His aim is to make early diagnoses. He will include, and integrate, physical, psychological and social factors in his considerations about health and illness.... Prolonged contact means that he can use repeated opportunities to gather information at a pace appropriate to each patient and build up a relationship of trust which he can use professionally. He will practice in co-operation with other colleagues, medical and non-medical. He will know how and when to intervene through treatment, prevention and education to promote the education of his patients and their families. He will recognize that he also has a responsibility to the community’.1 This deﬁnition reﬂects some undoubted strengths of primary care: closeness and continuity of the clinician–patient relationship, broad scope of care and em- beddedness within the wider healthcare system. But it still seems old-fashioned ∗ Throughout this book I will use the term ‘general practitioner’ unless I am speciﬁcally drawing a distinction between the subtly different roles represented by these different titles. I will also use the term ‘primary care’ to mean ‘primary health care’, though I acknowledge that in other contexts primary care includes social as well as health care. Introduction 3 Box 1.1 Examples of primary health care encounters. r A 63-year-old woman with a sticky eye asks her high-street pharmacist if there is anything she can buy over the counter for it. r A dentist ﬁnds a suspicious white lesion while doing a routine check-up of a 72-year-old woman smoker and offers to refer her urgently to an oral surgeon. r A 15-year-old schoolgirl visits an evening family planning clinic for a repeat prescription of the contraceptive pill. r A mother brings her 3-month-old baby to a community centre to be weighed and immunised. r A 24-year-old HIV-positive gay man attends for a routine blood test and a repeat prescription for his antiretroviral medication. r A 78-year-old man with diabetes and leg ulcers receives regular visits from both the district nurse (to bandage the ulcers) and the community diabetes team (to monitor the diabetes). r A 19-year-old single mother attends the accident and emergency department with a sore throat. r A community psychiatric nurse visits a 53-year-old woman with schizophre- nia every 2 weeks to assess the illness, administer a depot injection of medica- tion and provide support. r A multi-disciplinary community team including doctors, nurses, social workers and health advocates provides a ‘health bus’ offering a range of ser- vices to refugees and asylum seekers on an inner city estate. r An 82-year-old woman with fading vision and a strong family history of glaucoma visits an optometrist for a routine check-up. r A 50-year-old man with migraine that has not responded to medication from his GP attends an alternative health centre for a course of cranial osteopathy and aromatherapy. and stereotypical, not just because it appears to assume that the doctor is male, but also because it places ‘him’ very centrally in charge of the service and responsible for deciding what is best for the patient. The list in Box 1.1 shows some examples of primary health care problems. It is taken from a seminar in which some of my postgraduate students (GPs, community nurses, pharmacists and managers) told of the last encounter they had in primary care. It illustrates a number of features of contemporary primary care that challenge the Leeuwenhorst deﬁnition. 1 A multi-professional team. Most so-called GP surgeries or family practices in- clude several doctors, as well as practice and community nurses, dieticians, physiotherapists and counsellors, and there may be close links with an inter- preting or advocacy service for minority ethnic groups. Dentists, high-street optometrists, community pharmacists and sexual health clinicians (e.g. family planning) are part of the primary care service but usually have their own list of patients and keep separate records. Whilst in some countries (e.g. Germany), 4 Chapter 1 single-handed GPs (‘ofﬁce-based physicians’) remain the norm, in others the primary care organisation is a complex social system in which teamwork and coordination are essential. 2 Proactive as well as reactive care. Some primary care contacts are patient- initiated (someone feels unwell or worried, so they seek advice), but an in- creasing number are initiated by a clinician, perhaps via an automated recall system. Clinician-initiated consultations may be for the care of chronic ill- ness (e.g. diabetes, asthma, arthritis, depression), management of risk factors for future disease (e.g. low bone density), prevention (e.g. immunisation) or screening (e.g. cervical smears). In such circumstances, good care is not so much about making clever diagnoses but about the ‘three R’s’ (registration, recall and regular review), as well as supporting self-care (see Section 4.4). It is also about what Julian Tudor Hart once called ‘doing simple things well, for large numbers of people, few of whom feel ill’2 – a task that depends crucially on both continuity of care and high-quality administrative systems. 3 Population as well as individual focus. The primary care practitioner is increas- ingly seen as responsible for health at a population level. Modern IT systems in primary care enable individual patient data to be aggregated (i.e. anonymised and added together) to produce a picture of the overall health of the practice population that can inform the planning of primary care provision and the commissioning of secondary care services. The adverse health impact of poor environments (damp housing, dangerous streets, junk food outlets, sexually explicit media) and, conversely, the positive health beneﬁts of social support and healthy communities are important contributors to the overall disease burden in primary care. 4 The social and cultural context of illness. A major advance in primary care over the past 30 years has been the recognition that biomedical models of diagnosing and treating illness (see Section 2.1) are inadequate. Both the social origins of disease and the cultural dimension of the illness experience and self-management are increasingly taken account of in planning services and the advice offered to patients. GP surgeries in multi-ethnic communities often develop positive links with public, religious and voluntary sector organisations who may be able to address the patient’s wider social needs and/or provide ‘cultural brokering’ for ethnic minorities. 5 The centrality of the patient in his or her own care. The days of ‘doctor’s orders’ are long gone. Particularly in chronic illness, it is now seen as essential for the individual to understand the nature of the illness and take an active role in monitoring and treating it – often with lifestyle changes as well as (or instead of) medication. All this needs motivation, skills and practical support. Dif- ferent people have different personalities, learning styles and support needs. ‘Empowerment’, ‘self-management’ and ‘shared decision making’ are different ways of conceptualising the active involvement of the patient (see Section 4.4). 6 An advocacy role. According to one deﬁnition, an advocate is ‘someone who represents the views of another, without judgement, regarding a situation that affects them, in order to inﬂuence others’. This role is of course particularly crucial when the patient is vulnerable or disadvantaged in some way (e.g. Introduction 5 learning difﬁculties, limited language skills, lacking information or social cap- ital). In healthcare systems that rely heavily on the ‘empowered’ patient en- gaged in ‘self-care’, advocacy is increasingly essential to reduce inequities. 7 Multiple service models. The examples in Box 1.1 suggest that there is probably no universal formula for organising primary care. Rather, the service must be responsive to local needs, priorities and ways of working. New models of primary care such as drop-in clinics in high-street locations (such as NHS Walk-in Centres) and telephone advice services (such as NHS Direct in the UK), as well as private GPs, alternative practitioners and the voluntary sector (self-help groups and charities), often make an important contribution to the mixed economy of provision. Imaginative local schemes (e.g. travelling health buses) may be developed to make health care more accessible to hard-to-reach groups. An increasing proportion of hospital attenders in reality belong neither to accident nor emergency cases, but are people seeking advice on illness or perceived illness in areas where the primary care sector is underdeveloped or not trusted; some hospitals employ primary care clinicians to deal with these individuals. All these models increase choice for patients but add to the complexity of the system and the difﬁculty of studying it systematically. 8 Multiple interfaces. As Box 1.1 shows, many primary care problems are mild and self-limiting, while others are long-term and/or potentially serious, and require cross-referral within the primary care team (e.g. to a nurse or coun- sellor) or external referral (typically to a hospital specialist or perhaps to a social worker). In these days of evidence-based practice (see Section 2.2), many such conditions are managed by protocols and care pathways that in- corporate the different input of multiple professionals and that transcend the primary–secondary care interface. Consistency of care wherever care is deliv- ered, and close liaison across interprofessional, interorganisational and inter- sectoral boundaries, and the effective use of new technologies, is essential for a ‘seamless’ experience by the patient. These eight features characterise what might be called ‘the new primary health care’. Here are some further deﬁnitions of primary care and general practice, which capture this more contemporary perspective: ‘Primary care is ﬁrst-contact care, delivered by generalists, dependent (increasingly) on teamwork, which is accessible (both geographically and culturally), comprehensive (interested in old as well as new problems), co-ordinated, population-based (there is responsibility for ‘the list’ as well as the individual patient), and activated by patient choice’.3 ‘Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and participating in the context of family and community’.4 ‘The general practitioner is a specialist trained to work in the front line of a health- care system and to take the initial steps to provide care for any health problem(s) that patients may have. The general practitioner takes care of individuals in a society, 6 Chapter 1 irrespective of the patient’s type of disease or other personal and social character- istics, and organises the resources available in the healthcare system to the best advantage of the patients. The general practitioner engages with autonomous in- dividuals across the ﬁelds of prevention, diagnosis, cure, care, and palliation, us- ing and integrating the sciences of biomedicine, medical psychology, and medical sociology’.5 ‘General practitioners/family doctors are specialist physicians trained in the principles of the discipline. They are personal doctors, primarily responsible for the provision of comprehensive and continuing care to every individual seeking medical care irrespec- tive of age, sex and illness. They care for individuals in the context of their family, their community, and their culture, always respecting the autonomy of their patients. They recognise they will also have a professional responsibility to their community. In nego- tiating management plans with their patients they integrate physical, psychological, social, cultural and existential factors, utilising the knowledge and trust engendered by repeated contacts. General practitioners/family physicians exercise their professional role by promoting health, preventing disease and providing cure, care, or palliation. This is done either directly or through the services of others according to health needs and the resources available within the community they serve, assisting patients where necessary in accessing these services. They must take the responsibility for developing and maintaining their skills, personal balance and values as a basis for effective and safe patient care’.6 I ﬁnd all these deﬁnitions useful to some extent. They are, for the most part, both factually accurate and morally inspiring. They implicitly convey the mul- tiple roles played by today’s primary care practitioner – including clinical ex- pert (in the diseases and symptoms seen in the community); professional carer (of individuals with chronic disabling conditions); witness (to the illness nar- rative and the experience of suffering or loss); gatekeeper (and coadministrator of limited resources); member (and perhaps manager) of a multi-professional, interagency team and educator (of colleagues, patients and people at risk). But I also ﬁnd the deﬁnitions above rather dry. Some of them come from a previous era, written as they were before the major social changes – set out in Box 1.2 – had occurred. In addition, these worthy deﬁnitions lack the passion that I feel for my own clinical work in primary care, and some of them seem to skirt round the essence of what primary care actually is. I would like to ﬁnd a deﬁnition of primary care that expresses the pride I felt when, as a newly qualiﬁed hospital doctor, a patient ﬁrst said to me, ‘I wish you were my doctor’ and which encompasses the missing piece of the professional jigsaw that I had found so lacking in the organ-speciﬁc hospital specialties I had studied in my youth (see Table 1.2). I want a deﬁnition of primary care that incorporates the mixture of elation and terror that I felt when I got my ﬁrst ‘list’ (i.e. a list of some 2000 people, most of whom were not currently ill, but for whose care I was now responsible) – and the ethical and legal responsibilities that went with it. And ﬁnally, I want a deﬁnition Introduction 7 Box 1.2 Social changes that have inﬂuenced the scope and direction of primary health care in the past 25 years. Demographic changes Globalisation and mass migration, leading to multi-ethnic communities and language/cultural barriers in the consultation (Section 7.1) Ageing population (Section 7.1) New family structures, especially growth of single-occupancy households (Section 7.1) Changes in patterns of poverty and social exclusion (Section 7.4) Changes in disease patterns and understanding of their aetiology Increase in chronic incurable illness and comorbidity (Section 10.1) Increased recognition of the interplay between genetic risk, lifestyle choices and environment in the genesis of chronic illness (Sections 4.3, 7.3 and 8.4) Increased recognition of the importance of healthy communities (Chapter 9) Changes in delivery of health care Emergence of evidence-based medicine, replacement of ‘clinical freedom’ with standardised guidelines/protocols (Section 5.2) Shift from treating established disease to early detection (screening) and prevention (Section 8.3) Shift of place of care from hospital to community for chronic conditions (Section 10.1) New and diverse roles for nurses and professionals allied to medicine (Section 10.4) Increase in organisational complexity of care, especially across the primary– secondary care interface (Section 10.2) Changes in social roles and expectations Increased emphasis on patient autonomy, dignity, self-determination and in- formed consent; decrease in ‘doctor’s orders’ (Section 4.4) Decline in traditional sick role and rise in ‘self-management’and ‘expert patient’ (Sections 4.1 and 4.4) Rising expectation that society should change to accommodate the ill and disabled (Section 4.1) Changing role of women – decline of the full-time wife and mother (Section 7.2) Decline in public trust in doctors and nurses (Section 5.6) New deﬁnitions of professionalism (Section 5.6) Technological changes Increased dependence on technology for administering and coordinating care (Section 10.3) 8 Chapter 1 Standardisation of clinical categories and terms for electronic coding and record-keeping (Section 10.3) Capacity to generate powerful, population-wide epidemiological data from aggregation of routinely collected clinical data in primary care (Section 8.1) Universally available medical information (e.g. via Internet) leading to greater questioning by patients of medical advice (Section 8.2) Growth in high-technology medicine (but not necessarily in the accessibility of such options to everyone) Changes in the role of the state Challenges to professional self-regulation, shift from voluntary ‘quality improvement’ to compulsory ‘quality control’ (Sections 11.1 and 11.2) The ‘new public management’ – with emphasis on accountability, targets and centralised standards and protocols (Section 11.2) Social movements Rise of consumerism, leading to increased expectations of health professionals and decreased tolerance of quality gaps (Chapter 11) Growth in complementary and alternative medicine and re-emergence of humanism as a reaction to over-rationalist models of care of primary care that does not merely assert the importance of teamwork but which conveys the impoverished contribution invariably made by those who insist on ﬂying solo.† To get a handle on these intangibles, we need to move from descriptions of what happens in primary care to a consideration of why these things are important – that is, we need to shift our focus from the structure and process † That is not to say that being a ‘single-handed’ practitioner is a bad thing. There is considerable evidence that patients prefer their primary care to be provided on a small scale and that beneﬁts such as ‘a personal service’ and continuity of care are seen as a worthwhile trade-off for a more limited range of clinics.7,8 But single-handed practitioners will usually be the ﬁrst to tell you how much they value and depend on their professional friendship networks, their links with colleagues outside their own small practice and the refreshment they get from regular educational meetings, learning sets and so on. Good single-handed practitioners also tend to be especially adept at working in partnership with nurses, physiotherapists, pharmacists and so on. When I talk about ‘the impoverished contribution made by those who insist on ﬂying solo’, I am drawing attention to the real dangers of refusing to acknowledge the limitations of one’s own past training, present knowledge or professional role and those of failing to draw judiciously and creatively on the skills and expertise of others. As I emphasise in the section What is academic study?, ‘teamwork’ is one of the eight essential skills of the academic primary care practitioner, and Chapter 10 considers how this plays out in the complex health care systems of the twenty-ﬁrst century. Introduction 9 Box 1.3 Core values of primary care. Holistic. Primary care embraces the complexities and interactions of bodily systems, mental responses, family, community and sociocultural context. It also seeks continuity of care through time. Balanced. Primary care seeks a middle ground between breadth and depth of knowledge, between lay and medical models of illness and distress and be- tween active intervention and ‘leaving well alone’. Patient-centred. Primary care sees each patient as an individual and seeks to offer personalised rather than standardised packages of care. Rigorous. Primary care seeks to draw judiciously on multiple sources of evi- dence (the patient’s unique predicament, the relevant research literature and the wider family and social context) when considering the action to take in relation to a particular problem. Equitable. Primary care takes responsibility for social justice in the allocation of scarce resources; hence it works proactively with, and plays an advocacy role for, the disempowered, inarticulate and socially excluded. This may include challenging the educated worried well when they seek a disproportionate share of healthcare resources. Reﬂective. Primary care is always practised in conditions of ignorance and/or uncertainty. It requires a questioning attitude, willingness to revise provi- sional diagnoses in the light of emerging ﬁndings and the humility to defer to higher authority (the specialist, the parent, the patient) when appropriate. Developed from various sources.9,10–15 of primary care to the core values of primary care. Values are deﬁned by the Oxford English Dictionary as ‘principles, standards or qualities considered worthwhile or desirable’. The core values of primary care are those aspects of our practice which we hold dear, which give us satisfaction, for which we seek to perform especially well and for which we are disappointed if we fail to deliver on. Box 1.3 shows some core values of primary care. Table 1.1 summarises some important changes in the scope and organisa- tion of primary care in the past 30 years, and Table 1.2 shows the implications of these changes for how illness and its management are approached, using one condition (diabetes) as a worked example. You can see that there has been a fundamental reframing since the 1970s (when diabetes was a relatively rare condition treated in hospital by specialists who focused on lowering the blood glucose level) to the present day (when it is seen as a multifaceted con- dition affecting both the patient and the wider family and requiring active self-management and a coordinated and individualized package of multi- professional support). Table 1.2 should not be taken to imply that primary 10 Chapter 1 Table 1.1 Trends in the scope and organisation of primary health care. Feature Traditional general practice Modern primary health care Core business Diagnosis and treatment of Prevention, surveillance and support of acute illness chronic illness Typical encounter Reactive (patient-initiated) Increasingly proactive (clinician-initiated) Focus of care Uniprofessional Multi-professional (team-focused) (doctor-focused) Place of care Most encounters occur in the Diversity and choice in place of care GP surgery Principle of resource ‘Health for me’: resources ‘Health for all’: resources allocated by allocation allocated by patient demand population need Basis of clinical Clinical freedom (sometimes Evidence-based (often directed by decision making idiosyncratic) guidelines and protocols) Nature of clinician– ‘Doctor’s orders’: paternalistic Patient preference: shared decision patient relationship advice with limited information making based on informed choice Purpose of Paper-based and constructed Electronic and designed to organise the record-keeping as aide-memoire for individual work of multiple professionals around the doctors patient’s illness and provide aggregated data for monitoring disease trends care has driven these changes. Quite the contrary, it was hospital special- ists (both diabetologists and diabetes-specialist nurses) who ﬁrst recognised the need for these changes and worked to achieve them across the primary– secondary care interface.16 Profound shifts in the attitudes of GPs and practice nurses were needed, as well as education, improved administrative systems and new models of care across the interface (e.g. the introduction of advice hotlines, open-access appointments and ‘fast-track’ foot clinics). But once the sea change had occurred in how diabetes was conceptualised and managed, it ceased to be a disease that could be comfortably accommodated in a hospital setting. All this began to happen in the mid 1980s, when I was training to be a diabetologist and undertaking my ﬁrst research project – into the kinetics of insulin absorption in patients with ‘brittle diabetes’. I did not know at the time that my lack of fulﬁlment from my research project (and the feel- ing that I wasn’t getting anywhere despite collecting vast numbers of blood samples from poorly controlled patients) reﬂected the exciting paradigm shift shown in Table 1.2, nor that my decision to change career and enter gen- eral practice in 1989 marked the imminent shift in the care of a substantial Introduction 11 Table 1.2 An example of primary care principles and values: a new model of diabetes. New model informed by primary care Traditional biomedical model principles and values Diabetes Disease of the pancreas Multifaceted disorder arising from metabolic conceptualised (absolute or relative insulin defect, which leads to imbalance in multiple as deficiency) embedded systems (biochemical, endocrine, physiological, psychological, family/community, society) Cause seen in Damage to pancreatic cells Complex interaction between nature (genetic terms of and/or cellular resistance to risk), nurture (environmental mediators and insulin moderators) and culture (behaviours, norms and expectations of the group) Management a Correcting the deficiency Multiple dimensions and levels of care: focused on with insulin injections or a Developing a partnership for care medication b Drawing up a personal management plan b Ensuring compliance that reﬂects the patient’s goals and priorities c Providing culturally appropriate education and resources for self-care d Supporting positive lifestyle choices e Managing overall cardiovascular risk f Regular structured surveillance (‘annual reviews’) for early complications g Judicious referral for specialist assessment or management Main goals of Near-normal blood glucose Understanding, confidence, self-efficacy, management control well-being Avoidance of hypoglycaemia Reduction in overall cardiovascular risk Prevention of secondary complications (amputation, blindness) Social integration Personal goals of patient (e.g. pregnancy, marathon run, renewal of driving licence) Main model of Doctor-driven Self-management supported by care multi-professional team Main indicators Blood or urine testing Complex risk profile including HbA1c level of success Patient’s HbA1c level Lifestyle choices, e.g. smoking cessation, exercise Well-being Quality failures Critical events, e.g. hospital Surveillance at patient level detected via admission, death Regular, multidimensional audit at system level including process measures (e.g. data capture) and outcome measures (e.g. proportion of patients with blood pressure adequately treated) Structured review of critical and near-miss events 12 Chapter 1 proportion of people with diabetes in the UK from hospital clinics into primary care. Here is one ﬁnal deﬁnition that reﬂects not only a description of what hap- pens in primary care, but also the core values listed in Box 1.3. You will see that it is a reﬁnement of the initial back-of-envelope that I proposed on page 2. Primary health care is what happens when someone who is ill (or who thinks he or she is ill or who wants to avoid getting ill) consults a health professional in a community setting for advice, tests, treatment or referral to specialist care. Such care should be holistic, balanced, personalised, rigorous and equitable, and delivered by reﬂexive practitioners who recognise their own limitations and draw appropriately on the strengths of others. Box 1.4 summarises what I personally believe to be the deﬁning characteris- tics of primary care and what I have called the ‘four pillars of professionalism’ in this ﬁeld of practice. Later chapters in this book address these four pillars in more detail. Box 1.4 Deﬁnition and scope of primary health care: a summary. Primary health care has 10 deﬁning characteristics: 1 It provides the patient’s ﬁrst point of contact with the health care system. 2 It deals with both acute and chronic health problems regardless of age, sex or disease type. 3 It provides person-centred care to the individual, taking account of his or her family and the wider community. 4 It considers health problems in their physical, psychological, social, cultural and existential dimensions. 5 It is ideally delivered via an ongoing clinician–patient relationship, built over time and characterised by high levels of communication and trust. 6 It is proactive as well as reactive, promoting health and well-being by supporting healthy lifestyle choices and offering interventions to manage risk. 7 It takes responsibility for the health of the community as well as of the individual. 8 It has a particular role in the early stages of potentially serious illness when symptoms and signs are mild or non-speciﬁc. 9 It assumes an advocacy role for the patient when needed (and/or works ﬂexibly with others who take on this role). 10 It strives to make efﬁcient use of health care resources through coordinating care, working with other professionals and managing the interface with other specialities. Introduction 13 To practice this specialty, the primary care practitioner must be competent in three areas: r Clinical care r Communication r Management Professionalism in primary care rests on four pillars: r Ethical: drawing on core values, principles and virtues r Scientiﬁc: adopting a scholarly and reﬂective approach to practice, including (but not limited to) the use of best up-to-date research evidence in clinical decisions r Organisational: addressing issues such as access, equity, relevance to social need, efﬁcient use of resources and so on r Educational: taking ongoing responsibility for continuous professional development of oneself and one’s staff Developed from various sources6,9,10–15 ; see text for further discussion. 1.2 What is academic study? All the deﬁnitions in the previous section point to an important conclusion: primary health care is not itself an academic discipline. In the eyes of the people writing these deﬁnitions, primary care is a practice rather than a theory, based on ‘doing something’ rather than ‘thinking in the abstract’. For those with the time and inclination to take an academic perspective, we might say that primary care is a problem-oriented ﬁeld of study that draws variously on a range of concepts and theories drawn from different disciplines. If you study primary care from such a perspective, you may initially be frustrated at the intellectual fuzziness in this ﬁeld of study compared to (say) the kind of well- demarcated subject areas that are taught in universities (e.g. biochemistry, mathematics). Before the end of this chapter, I hope to have persuaded you that primary care has (or could have) a robust academic basis. But before I take on that argument, I would like to consider in more detail what ‘academic study’ actually means. The German academic, philosopher and educationist Friedrich Wilhelm von Humboldt (1767–1835), who founded Berlin’s ﬁrst university and who was once described as ‘the last universal scholar in the ﬁeld of the natural sciences’, believed that there are four core skills that the graduate of academic training will display. He or she will be able 1 To think constructively 2 To argue coherently 3 To judge dispassionately 4 To solve problems creatively As well as these traditional academic skills, I would further add four essential skills for the academic scholar in the twenty-ﬁrst century. I have called these 14 Chapter 1 contemporary academic skills: 5 To communicate ideas and concepts to the non-expert 6 To work effectively and efﬁciently‡ as a member of a multi-disciplinary team 7 To manage knowledge – that is to ﬁnd, evaluate, summarise, synthesise and share information 8 To adapt appropriately to change If these eight core skills (four traditional, four contemporary) are taken as the deﬁning features of an academic approach, such an approach is entirely congruent with the core business of primary care and with primary care as a fundamentally practical (and inherently fuzzy) ﬁeld of enquiry.§ Others might deﬁne academic study as to do with abstract thoughts rather than real-world problems or practical action, and I guess those are the people who believe that primary care has no academic basis! I return to contemporary academic skills in Section 5.1 when I consider the nature of generalist knowledge. In order to unpack academic study further, we need to consider the notion of an academic discipline. If you ask your children what ‘discipline’ is, they would probably say ‘punishment for breaking the rules’ or (as self-discipline) ‘behaving according to a particular set of rules’. In the world of academia, a discipline is a body of knowledge that has a well-deﬁned set of intellectual conventions and rules. There are two sorts of academic discipline. The ﬁrst – primary or theoretical disciplines – comprise the traditional academic ‘subjects’that have been offered at universities for decades. Examples of primary disciplines include physiol- ogy, immunology, sociology, statistics, philosophy, history, geography and so on. In Chapter 2, I will refer to these as ‘the ologies’. Each of these has an agreed body of knowledge (we can generally say that X is or is not part of the disci- pline), an agreed focus and set of concepts (the ‘stuff’ that is deemed worthy of study by experts in the discipline), a theoretical model of how these concepts ‡ Effectiveness is sometimes deﬁned as ‘doing the right thing’ and efﬁciency as ‘doing things right’. The former is essentially a clinical dimension; the latter is largely an economic one. If I make a tasty and nutritious meal, dirtying only the minimum of pots, for someone who is not hungry, I have done something efﬁcient, but not effective. If I jump into water to rescue a drowning person but ruin my expensive watch in the process, I have been effective but not efﬁcient since I could (perhaps) have achieved the same outcome by removing the watch ﬁrst. § If you are interested in seeing how these academic skills link to an ofﬁcial policy map of the practical skills and ‘know-how’ needed for delivering primary care in the twenty-ﬁrst century, take a look at the 2004 report from the US Society of General Internal Medicine on ‘The Future of General Internal Medicine’.9 As well as expertise in providing comprehensive long-term care to an unselected population, this national task force identiﬁed the following skills as essential for the general internist practising in a community setting: effective communication with patients and colleagues, evidence-based practice (including critical thinking and knowledge management), reﬂection and lifelong learning, leadership and team working, professionalism and adaptability to a changing world. Introduction 15 Anthropology Psychology Sociology Philosophy Epidemiology and ethics Arts and literature Biomedical sciences Pedagogy PRIMARY HEALTH CARE The clinician–patient Quality assurance relationship and improvement Evidence-based practice Resource allocation Research Information management Teaching, training and Co-ordination of care professional development Figure 1.1 Primary health care: underpinning disciplines (upper half) and key themes in contemporary practice (lower half). ﬁt together (see Section 1.3) and a more or less agreed approach to research design (immunologists, for example, do experiments on rabbits, whereas his- torians study ancient manuscripts and philosophers discuss premises and what can be deduced from them). Within each theoretical discipline, schol- ars generally agree about the main research questions and about what counts as good (or poor) research. Until recently – with a few notable exceptions – scholars from different primary disciplines rarely exchanged ideas with one another. The second sorts of discipline – secondary or applied – focus on problems rather than concepts and theories. Scholars in secondary disciplines consider real-world issues from many different angles, drawing eclectically on the dif- ferent primary disciplines to address different dimensions of the problem. Examples of secondary disciplines include business studies (which draws on economics, marketing, anthropology and organisational theory), education (which draws on learning theory, linguistics and psychology) and primary health care, whose underpinning disciplines are illustrated in Figure 1.1. Philosopher Thomas Kuhn introduced the concept of a paradigm (a particular scientiﬁc approach characterised by four things: concepts, theories, methods and instruments).17 If you are interested in the philosophical basis of different approaches to primary care, I recommend Kuhn’s book, which is short, inspiring and easy to follow. 16 Chapter 1 Table 1.3 Primary care: textbook versus gritty reality. The textbook The reality Diagnoses Non-specific conditions Families Unsupported individuals Housing Homelessness Continuity of care Episodic care Evidence and guidelines Pragmatic solutions Compliance Compromise Predictability Uncertainty Healthy lifestyle choices by individuals Structural and practical barriers to healthy choices Adapted from Murdoch.18 Figure 1.1 raises an important question: Given the number of different un- derpinning disciplines relevant to the academic study of primary care, where should one start? The answer is, with a real-life problem. The theoretical literature often only makes sense when applied to a practical problem; the dif- ferent theoretical perspectives represented by the ‘ologies’ can be thought of as different ‘lenses’ through which to view real-life problems. Strictly speaking, secondary disciplines such as pedagogy are not ‘disciplines’ at all but ‘applied ﬁelds’ – since a discipline in the pure sense is a single conceptual framework with its own conventions and rules. But in practice, the word ‘discipline’ is now used for both theoretical and applied ﬁelds of study. Please do not assume that the only disciplines relevant to primary health care problems are the ones shown in Figure 1.1, nor that all the disciplines shown will be relevant to all primary care problems. Table 1.4 sets out the deﬁnition and scope of some key underpinning disciplines of primary care, some of which for clarity, are not shown in Figure 1.1. You might like to modify Figure 1.1 by adding and subtracting different disciplines in a way that allows you to make sense of particular problems in the context of your own work in primary health care. Like the rest of this book, Figure 1.1 is intended to set the scene for further reﬂection and discussion, not to be memorised as ‘fact’. Traditionalists often bemoan the fact that universities are offering their stu- dents an increasing array of secondary disciplines from in-ﬂight catering to Frisbee throwing and (probably rightly) argue that the main task of a univer- sity is to introduce its undergraduates to bodies of theoretical knowledge and the rules and conventions of the primary disciplines. It is certainly true that one can (and some universities do) approach practical subjects in a superﬁ- cial, unrigorous way and that all applied ﬁelds of study (including primary care) have a continuing responsibility to demonstrate their academic rigour if they are to be considered credible. Whilst non-academic (e.g. continuing pro- fessional development) courses can offer useful tips and tools for the primary care practitioner, the academic study of primary care problems is impossi- ble unless students have a sound theoretical grasp of the main underpinning Introduction 17 Table 1.4 Underpinning academic disciplines for primary health care. Contribution to the study of Discipline Deﬁnition primary health care Primary disciplines Anthropology The study of human cultures and how Culture, values and identities they have evolved and inﬂuenced each (includes organisational culture, other professional culture and so on as well as the ideas and practice of different ethnic groups) Biomedicine The study of the structure and function Diseases and how to treat them of the human body, its disease processes and treatment Epidemiology The study of disease patterns in Prevention and management of populations diseases and risk factors in populations (both infections, e.g. HIV, and non-infectious, e.g. obesity) Health economics The study of the production, distribution Models of payment for primary and consumption of goods and services care. Issues of affordability and in health care access Law (strictly, The study of the body of enacted or Legal rights of patients, legal jurisprudence) customary rules recognised by a obligations of health community as binding professionals. Informs the study of medical ethics Philosophy The study of the nature of knowledge The nature of knowledge, e.g. (ontology) and how it is used in practice differences between scientific (epistemology). Also, moral philosophy knowledge and experiential or ethics which concerns what is the knowledge or know-how right way to live and behave Psychology The study of mind and behaviour. Motivation, incentives, rewards, Factors that inﬂuence human beings to emotional needs. Inﬂuence (e.g. act, particularly cognitive and emotional impact of ‘medical advice’ vs. inﬂuences ‘lay advice’ on patients’ decisions) Social psychology The study of social inﬂuences on human Interpersonal inﬂuence, roles, behaviour modelling, norms Sociology The study of human society and the Organisational, family and peer relationships between its members, structures. Group norms and especially the inﬂuence of social values. Social inﬂuences on structures and norms on behaviours and clinician behaviour (e.g. practices. Includes medical sociology adoption of guidelines) (the study of the norms, behaviours and social networks of health professionals) (Continued ) 18 Chapter 1 Table 1.4 (Continued ) Contribution to the study of Discipline Definition primary health care Secondary disciplines Pedagogy The study of learning – in particular, Acquisition and application of how knowledge can be understood, knowledge by both patients and used and valued professionals Health promotion The study of strategies and practices Disease prevention, healthy aimed at improving the health and lifestyles well-being of populations Organisational The study of the structure and Organisational factors inﬂuencing studies function of organisations accessibility, process of care, financial efficiency and health outcomes Political sciences The study of government structures Impact of different political and their function in developing and structures on the effectiveness of implementing policy policymaking (includes ‘modernisation’ of urban bureaucracies, citizen involvement) primary disciplines such as the biomedical subject areas (physiology, pharma- cology, epidemiology and so on), social sciences (sociology, anthropology) and psychology. For this reason, I believe that primary care is a particularly difﬁcult sub- ject to study. It should be considered as a postgraduate (advanced) discipline by people who recognise its complex foundations, and not as ‘the easy bits’ of biomedicine. For this reason also, I believe that the study of primary care is best accomplished through open and pluralist discussion in learning groups that are both multi-disciplinary (i.e. comprising individuals who studied different theoretical disciplines as undergraduates) and multi-professional (i.e. compris- ing individuals who have a wide range of roles in their working lives – and hence different perspectives on primary care problems). Professor J. Campbell Murdoch has drawn attention to the difference be- tween the primary care of most textbooks and the reality with which most of us deal in our daily practice (Table 1.3).18 As Murdoch pointed out, most of us spend our ﬁrst few years in clinical primary care ‘unlearning’ the tidy theories and taxonomies of textbook biomedicine and becoming more or less comfortable with the ‘grey zone’ of practice we have found ourselves in. We learn, more or less, to manage without the things we expected to ﬁnd (the left-hand column in Table 1.3) and to cope with what we actually ﬁnd (the right-hand column). We also learn that the knowledge base of primary care is potentially inﬁnite and that however hard we try, we cannot ever get on top of everything. Introduction 19 Much of primary care is characterised by untidiness, uncertainty and many different potential approaches to a single problem. The notion of uncertainty, and the gap between theory and reality, will be recurring themes throughout this book. The academic study of primary care includes the theoretical study of ‘grey areas’ and uncertainty in clinical method. It also includes the use of multiple theoretical perspectives to build up a rich picture of a complex and contested ﬁeld of study. You can probably begin to see why the contempo- rary academic skills of teamwork, knowledge management, communication and adaptability to change are going to be particularly critical to the study of primary care. 1.3 What are theories – and why do we need them? Theories are conceptual models that help us make sense of reality.19 Look at the example of Dr Begum and her colleagues in Box 1.5. The clash of approaches between these three health professionals results from the fundamental way they conceptualise the problems they deal with in their work. Dr Begum’s conceptual model of primary health care is one where patients suffer from diseases, which have causes (and risk factors) and which respond to a greater or lesser extent to speciﬁc treatments, which in turn have been tested in ran- domised controlled trials. In other words, she uses the biomedical model (see Section 2.1) – a rational, scientiﬁc model that underpins anatomy, physiology, biochemistry, cardiology, immunology and so on. If Dr Begum were to conduct a research study, it would probably be a randomised controlled trial or a survey of symptomatology in a particular disease. Box 1.5 Different perspectives on primary care problems. A young GP, Dr Begum, works in a busy group practice. She is a keen pro- ponent of evidence-based medicine. She considers every problem in terms of ‘diagnosis’, ‘prognosis’, ‘therapy’ and so on. She searches for research evidence on the Internet. She carefully evaluates the research evidence and draws con- clusions that she believes are rational and logical. But she cannot understand why the other doctors in her practice (who are older and more experienced) do not share her enthusiasm for exploring the research literature and apply- ing the results in practice. Her practice nurse, Mrs Perkins, suggests, ‘The best thing to do is spend a bit of time listening to the patient, and getting to know their family and their situation, so you can view their illness from their point of view and in its proper context’. One of the older doctors, Dr Brown, has a different piece of advice, ‘My dear, when you have accumulated as many years of experience as I have, you won’t need to rely quite so much on your super-scientiﬁc research evidence. You’ll be able to improvise like the rest of us. When people come in asking for some new fangled medication, you’ll be able to get them out the door believing they never wanted it in the ﬁrst place’. 20 Chapter 1 Mrs Perkins has a different model – based centrally around the achievement of empathy through shared experience and active listening. The question for her is not ‘what is the diagnosis?’ but ‘who is this patient and what is he or she going through?’ Note that Mrs Perkins views her work not as doing something to the patient but as being there for the patient. Her work is built around a ‘care’ relationship, not a ‘cure’ relationship, and the mental model for the former is not a rational (scientiﬁc) one but an experiential (phenomenological) one (see Section 11.5).20 If Mrs Perkins were to do a research study, it might take the form of an in-depth case study, written up as a detailed narrative, of a patient whose illness was an epic struggle for survival or quest for meaning.21 Dr Brown’s model of primary care problems is different again. Like Dr Begum, he is interested in inﬂuencing the course of the illness, but his ideas about treatment are not primarily biomedical. He uses the word ‘improvise’ – a term more frequently used in relation to jazz music or unscripted theatre. This suggests that his mental model is based on the view of general practice as an art – where the demonstration of a bit of priestly authority and mystical divination might just help the healing process. The conceptual world of artistic improvisation has little place for ‘causes’ and ‘effects’, but has much to do with the performative relationship between the ‘actor’ and his or her ‘audience’, the roles they assume and the games they play. Dr Brown might even take a psychodynamic model of his work – the notion that in general practice, trivial illness is the vehicle through which painful subconscious (emotional) issues are brought for discussion (the so-called hidden agenda – see Section 6.3).22 If Dr Brown were to conduct a research study, it might be a series of reﬂective discussions between him and his fellow GPs, in which they work through a series of challenging patients and how they attempt to use their professional position (what Balint called ‘the doctor as the drug’– see Section 6.3) to promote emotional (and thereby symptomatic) healing in their patients.22 If you have a conventional hospital-based medical training, you will almost certainly feel most comfortable with the rational, scientiﬁc model. If you come from a nursing background, the ‘care’ model might make more sense to you, because much of your undergraduate training would have been based on it (and because much of your work is to do with caring). However, nursing curricula throughout the world vary considerably, and scientiﬁc models are increasingly privileged (perhaps reﬂecting the emergence of the extended role of the nurse in diagnosis, treatment and so on). If you are a British GP, or come from a comparable health care system (such as the Netherlands or New Zealand), you may well be most comfortable with an ‘artistic’ model of general practice and/or with models that consider subconscious, as well as conscious, inﬂuences on behaviour. Which model is correct? Think about this for a little before you read on. If you believe that any one model is the ‘correct’ way to conceptualise ev- ery problem you encounter in primary health care, you have probably not seen very many real-life problems or listened to many people from other professional (and lay) backgrounds. You have probably also not understood Section 1.2 about the multiple underpinning disciplines of primary care! But Introduction 21 if you are an experienced generalist, and especially if you work a lot in multi- disciplinary teams, you will almost certainly know that different conceptual models help us with different sorts of problems – and allow us to have multi- ple ‘takes’ on the same problem. A rational, ‘evidence-based’ model helps us when the problem can be couched in the taxonomy of a speciﬁc disease (or a differential diagnosis), whereas the ‘improvisation’ model might become dom- inant when the problem is best expressed as ‘Mrs Jones making yet another appointment after all those negative tests’. Different primary disciplines are generally based on different conceptual models, though most of the hospital-based medical disciplines share a com- mon biomedical model (in which problems can be analysed at different levels including the molecule, the cell, the organ and so on). There are many other conceptual models relevant to primary care that I have not yet mentioned. If you work in a managerial or executive role, your mental model of primary care is probably one of a complex organisation and you will see problems in terms of appropriate skill mix, effective teamwork, efﬁcient project management and so on. You will have a natural tendency to analyse problems at the level of the team (e.g. particular project groups). And if you work in social services, you are more likely to view problems in terms of the social structures, norms and relationships that produce particular behaviours – that is, your concep- tual model will be the social system and your unit of analysis will be the social group (e.g. teenage mothers). Take another look at Table 1.4, which illustrates the diversity and scope of academic primary care. You will probably return to it (and perhaps add to it) when you begin to conceptualise and theorise about the primary care problems you meet in your own practice. Once you begin to do that, even if you do not ﬁnd any easy answers, you can call yourself an academic primary care practitioner. References 1 Leeuwenhorst Working Party of European General Practitioners. The General Practitioner in Europe: A Statement by the Working Party Appointed by the European Conference on the Teaching of General Practice. Leeuwenhorst, Netherlands: WONCA Europe; 1974. 2 Hart JT. A New Kind of Doctor. London: Merlin Press; 1988. 3 Gordon P, Plamping D. Primary health care: its characteristics and potential. In: Gordon P, Hadley J, eds. Extending Primary Care. Oxford: Radcliffe Medical Press; 1996:1–15. 4 Donaldson M, Yordy K, Vanselow N. Deﬁning Primary Care: An Interim Report. Washington, DC: Institute of Medicine; 1994. 5 Olesen F, Dickinson J, Hjortdahl P. General practice – time for a new deﬁnition. BMJ 2000;320:354–357. 6 European Academy of Teachers of General Practice. European deﬁnition of general practice/family medicine. Available at http://www euract org/html/page03f shtml; 2002. 7 van den Hombergh P., Engels Y., van den Hoogen H., van Doremalen J., van den Bosch W., Grol R. Saying ‘goodbye’ to single-handed practices; what do patients and staff lose or gain? Fam Pract 2005;22:20–27. 22 Chapter 1 8 Campbell JL, Ramsay J, Green J. Practice size: impact on consultation length, workload, and patient assessment of care. Br J Gen Pract 2001;51:644–650. 9 Larson EB, Fihn SD, Kirk LM, et al. The future of general internal medicine: report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the domain of general internal medicine. J Gen Intern Med 2004;19:69–77. 10 Toop L. Primary care: core values. Patient centered primary care. BMJ 1998;316:1882–1883. 11 McWhinney IR. Primary care: core values. Core values in a changing world. BMJ 1998;316: 1807–1809. 12 Dixon J, Holland P, Mays N. Primary care: core values. Developing primary care: gate- keeping, commissioning, and managed care. BMJ 1998;317:125–128. 13 Roberts J. Primary care: core values. Primary care in an imperfect market. BMJ 1998;317: 186–189. 14 Neuberger J. Primary care: core values. Patients’ priorities. BMJ 1998;317:260–262. 15 Jones R. Core values in primary care. BMJ 1998;317:1394–1396. 16 Greenhalgh T. Shared care for diabetes: A systematic review. Occasional Paper 67. London: Royal College of General Practitioners; 1994. 17 Kuhn TS. The Structure of Scientiﬁc Revolutions. Chicago: University of Chicago Press; 1962. 18 Murdoch JC. Mackenzie’s puzzle – the cornerstone of teaching and research in general practice. Br J Gen Pract 1997;47:656–658. 19 Alderson P. The importance of theories in health care. BMJ 1998;317:1007–1010. 20 McCance TV, McKenna HP, Boore JR. Exploring caring using narrative methodology: an analysis of the approach. J Adv Nurs 2001;33:350–356. 21 Frank A. Just listening: narrative and deep illness. Fam Syst Health 1998;16:197–216. 22 Balint M. The Doctor, His Patient and the Illness. London: Routledge; 1956. CHAPTER 2 The ‘ologies’ (underpinning acade

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