more_vertThe Sustainable Development Goals (SDGs) are now steering the global health and development agendas. Notably, the SDGs contain no mention of primary health care, reflecting the disappointing implementation of the Alma-Ata declaration of 1978 over the past four decades. The draft Astana declaration (Alma-Ata 2·0), released in June, 2018, restates the key principles of primary health care and renews these as driving forces for achieving the SDGs, emphasising universal health coverage. We use accumulating evidence to show that countries that reoriente their health systems towards primary care are better placed to achieve the SDGs than those with hospital-focused systems or low investment in health.
Preference: General Practice and Primary Care
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[Articles] Population effectiveness of opportunistic chlamydia testing in primary care in Australia: a cluster-randomised controlled trial
These findings, in conjunction with evidence about the feasibility of sustained uptake of opportunistic testing in primary care, indicate that sizeable reductions in chlamydia prevalence might not be achievable.
[Articles] The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial
A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care.
[Perspectives] Picturing health: global primary health care
I started my application to medical school by writing my belief that “every human being should have equal and fair access to adequate health care”. 18 years later and now a primary care academic clinical fellow, I stand by this belief. It was by no coincidence that the 1978 Declaration of Alma-Ata was signed at the International Conference on Primary Health Care. Global primary health care is key to unlocking inequality and inequity—it works not only to achieve the definition of health as physical, mental, and social wellbeing but also works to achieve family, community, and spiritual wellbeing.
[Comment] Steroid injection or wrist splint for first-time carpal tunnel syndrome?
Carpal tunnel syndrome is a common cause of hand pain, sensory disturbance, and weakness affecting daily activities and quality of life.1 It is a frequent reason for medical consultation and up to 40% of patients are managed exclusively in primary care.2 Treatment goals are to relieve symptoms, improve function, and prevent disease progression to nerve damage. The two treatments that constitute standard care for most patients with first-time carpal tunnel syndrome are night splinting and local steroid injections.
[Correspondence] Improve access to quality primary care for patients with anxiety or depression
Graham Thornicroft (Feb 17, 2017, p 636)1 suggests that teams working on the Improving Access to Psychological Therapies (IAPT) programmes have helped increase treatment rates for adults with anxiety or depression (from 24% in 2007, to 37% in 2014).2 However, from a primary care perspective, the proportion of people with these disorders who receive psychological therapy is still small.
[Correspondence] Improve access to quality primary care for patients with anxiety or depression – Authors’ reply
We thank Tony Kendrick for raising the important issue of how few people with anxiety or depression in the UK actually receive any treatment. In high-income countries like the UK, psychological treatment services, such as the Improving Access to Psychological Therapies (IAPT) programme, have an important role in increasing choice and access to evidence-based treatments, alongside strengthening primary care.
AMA critical of Qld Pharmacy Inquiry recommendation
The Queensland Pharmacy Inquiry has recommended that options be developed for what it is describing as “low-risk” prescribing by pharmacists.
The AMA has condemned the recommendation, saying patients will lose out if it is adopted.
Recommendations are listed in the Queensland Parliament’s Health, Communities, Disability Services, and Domestic and Family Violence Prevention Committee Report into the Establishment of a Pharmacy Council and Transfer of Pharmacy Ownership
Chairman of the Inquiry, Aaron Harper said: “We see potential for pharmacists to do more than they currently do – with some prescribing of medications in low-risk situations and subject to a range of safeguards.”
But AMA President Dr Tony Bartone said that and some other recommendations add up to bad news for patients.
“The Report contains recommendations to expand the role of pharmacists, including in relation to the prescribing of medications,” Dr Bartone said.
“It is well known that the more that other non-medical health professionals are involved in prescribing, the higher risks of medication error and adverse reactions.”
Other recommendations include lowering the minimum age for pharmacist-administered vaccinations to 16, retaining current pharmacy ownership laws, and establishing a new pharmacy advisory council for the State.
Dr Bartone said GPs were only trained primary health professionals who have the skills needed to properly and comprehensively diagnose patients, prescribe the right medications, and refer patients to other health care providers as appropriate.
“These are skills that come from years of observing and examining patients, and understanding how text books and the real live patient overlap,” he said.
“Clinical training is an art that has its foundations over the centuries, and cannot be learnt by simply and solely reading texts.
“GPs currently work closely with their pharmacist colleagues on a daily basis, and respect the unique skills they bring to the care of patients, particularly with respect to the quality use of medicines.”
Dr Bartone said the AMA was in the middle of a real effort to introduce the medical home concept in Australia, where GPs are able to coordinate patient care, with full access to a patient’s medical history.
“But let me be very clear about this Report, which completely overlooks the reality of quality primary health care,” he said.
“It totally ignores the well-understood need in our health system to strengthen the coordination of care, and the need to encourage patients to have a long-term relationship with a usual GP or general practice.
“The Report also opens up a serious conflict of interest for pharmacists who will gain commercially through prescribing of medications, and then being able to dispense them.
“We already know that pharmacies sell many complementary medicines that are not backed by clinical evidence. This highlights the retail pressure they are under to sell products to consumers regardless of patient need.
“The recommendations in this Report, if adopted, would set Australia on a dangerous course.”
Dr Bartone said Australia had a GP-led model of care that is the envy of the world, with GPs highly accessible in most parts of the country.
Australia has primary care outcomes that are second to none.
He said the Australian community deserved better than what was recommended in the Report. The focus of policymakers, he said, needed to be on building on the proven model of GP-led care, rather than undermining it by giving in to the retail interests of the pharmacy sector.
“Any access concerns cannot be solved by providing a second-best alternative,” Dr Bartone said.
CHRIS JOHNSON
Stalwart of AMA and community passes away
OBITUARY
Dr David John Doidge ANDREW
RFD MBBS FRACGP Dip.Obst RCOG
1944 – 2018
Dr David John Doidge Andrew passed away unexpectedly on October 3, 2018.
A Fellow of the Australian Medical Association, his outstanding commitment to the organisation and the community in general stands as an inspiration to all.
Born, January 27, 1944, Dr Andrew graduated from The University of Melbourne in 1968 and joined the Australian Medical Association the following year.
On graduation, Dr Andrew worked in Auckland, New Zealand before working as a visiting medical officer at The Royal Children’s Hospital and The Royal Women’s Hospital. Dr Andrew also worked as an obstetrics and gynaecology Registrar in Wellington and Auckland in 1972 and 1973.
In 1971 Dr Andrew joined the Royal Australian Navy Reserve. He retired with the esteemed rank of Surgeon Commander in 2009.
Dr Andrew practised as a general practitioner for the Whittlesea and Epping Medical group from 1974 to 1975 before starting a solo practice in Epping in 1976. He retained this solo practice until 2009.
Since joining the AMA Victoria in 1969 and becoming an active member in the late 1970s, Dr Andrew has served as:
- Secretary and Chair of Northern Subdivision
- AMA Victoria Council representative for the Northern Division of General Practice
- AMA Victoria representative for the Department of Veteran Affairs on the Local Medical Officer Advisory Committee
- Member of the AMA Victoria Section of General Practice
- Treasurer of the Section of General Practice
- Member of the AMA-RACGP liaison Committee.
Throughout his career Dr Andrew has worked as a locum doctor intermittently in rural Victoria. He has been a strong advocate for doctors working in rural areas and for rural health.
One of Dr Andrew’s major concerns for the medical profession is the loss of obstetric skills in the new generation of doctors.
Outside of his active role with the AMA, Dr Andrew has also served as the Director of the Northern Division of General Practice.
Dr Andrew has been a long-time supporter and active member of the Australian Medical Association. Through his various roles, he has made an outstanding contribution to the organisation. He was a most worthy candidate for admittance to the Roll of Fellows.
Beloved husband to Vaoese, proud father of Jason, Bronwyn, Peter, Stephanie and David, and proud grandfather of Maximus, Austin, Celeste, Matilda, Alice and Wolfgang. He is sorely missed.
Paying for performance
BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY
Assessing the quality of care in general practice can mislead if it is not based on observations of that care. Asking doctors what they have done and judging quality on the basis of medical records is not good enough.
The perils of judging what happens in the clinical setting on the basis of what doctors record is obvious in a study of a health care funding agency, in this case the NHS, ceasing to pay doctors for providing additional services it regarded as so desirable that for which it had previously provided incentive payments.
A paper in the September 5 issue of the New England Journal of Medicine by five authors from the National Institute for Health and Care Excellence in the UK [N Engl J Med 2018; 379:948-957 or www.nejm.org/doi/full/10.1056/NEJMsa180149] used electronic medical records from 2010 to 2017 in UK general practices to assess the effects of removing, in 2014, 12 incentives linked to 12 indicators and compared the outcomes for six indicators where the incentives were maintained.
The study was set in 2,819 English general practices with more than 20 million registered patients. There were big drops – 62 per cent – in records of indicators ‘related to lifestyle counselling for patients with hypertension’ when the incentives were withdrawn.
The authors noted that reductions in the documentation of clinical processes varied widely among conditions – from a 6 per cent reduction for smoking counselling to a 30 per cent decrease in documenting BMI of 30 per cent among patients with mental illnesses.
The authors observe: “Several studies show that what is gained on incentive introduction is essentially lost on incentive withdrawal.”
But – and here’s the rub – what was gained? The authors note: “The uncertainty about whether changes in the documentation [my italics] of care represent true changes in patient care.”
We do not know to what extent the reduced documentation of the incentivised clinical behaviours reflected reduced clinical care.
Other than the automatically updated markers (like lab tests) in the records, frequencies of other interventions were measured purely on their action being documented.
It is quite possible that the desired actions were still taking place at a similar rate, but were simply not documented. Ask any busy clinician about how record keeping can diminish when the day is long or when there’s an emergency. It is hardly surprising that documentary markers decrease after removal of incentive.
An example of the disconnect between the record and the action given in the paper is that of prescription of long-term contraceptives. Although the records suggested a fall in prescriptions after the withdrawal of the incentive, actual use assessed from other sources increased.
I hold to the view, based on long observation, including a five-year stint chairing a district health board in Sydney, that our health system would grind to a halt were it not for the altruism of health professionals, including doctors. Yes, getting the right mechanism for paying for health care matters intensely, and doctors are well paid, but creating the conditions where doctors can express and apply more altruism in the system may offer the best yield in clinical care. Worth an experiment, anyway.
Recently I read Out of the Wreckage: A New Politics for an Age of Crisis by British journalist George Monbiot. It is an exciting and optimistic book despite the prevailing uncertainties in many democracies.
A major thesis is that the distinctive human attribute which has led humanity to its current zenith, and which Monbiot considers to be critical to our approach to the future, is altruism – by which he means people looking out for others and caring for them. You can assess the strength of his argument for yourself or watch him on YouTube www.youtube.com/watch?v=uE63Y7srr_Y
If you consider that more needs to be done in improving health care, proceed cautiously with the idea of incentive payments.
Do not be beguiled in assessing their effectiveness by the documentation of process. Rather, measure their effects on actual care and outcomes. And when considering what doctors and other health professionals do day by day and how this might be strengthened, remember that altruism – doing caring things without concern about reward – still ranks highly on the scale of what motivates them. This is why they do what they do. Make it easier for them.