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Primary Care and the Health of the Public


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Thursday, 12 November 2020

Primary Care and the Health of the Public

By Professor David Colin-Thomé, OBE, chair of PCC and formerly a GP for 36 years, the National Clinical Director of Primary, Dept of Health England 2001- 10 and visiting Professor Manchester and Durham Universities.

As the Covid-19 Pandemic unfolds in the UK, England’s public health system’s response when compared internationally seems to be failing us. Crises often highlight existing system weaknesses, and an over reliance on centralised decision making and equally for delivery of services such as test and trace, has arguably contributed significantly to failure. In contrast NHS centralised decision making led to the speedy transformation and high quality delivery of hospital intensive care services. Health crises although unwanted can generate expedient responses of long term benefit. Centralisation of benefit for short term emergency responses but localism for sustained benefit

Do we need a new approach to public health? A more fundamental question, has traditional public health been of value to primary care? Within the NHS, primary care is by far the most public facing service and general practice uniquely in the NHS, serves a registered population.

The author of this paper has been a lead advocate for population health – defining it as the health outcomes of a group of individuals and describing population health management as ‘a logical extension to the strong generalist tradition within general practice. GPs and primary care staff are embedded in the community and well-placed to make the most of their knowledge of patients and the factors affecting their health’. I advocate that as government policy is more primary care focused than at any time in my lengthy career, a more encompassing local approach to the health of the public is essential.

Prevention, early intervention, and health promotion all require a focused overview of a practice’s population. Current concepts of population health argue that practitioners need to have broad views of the health trends and demographic characteristics of the populations they serve even when practicing with individual patients. Managing care in any system with limited resources (which means all systems) requires that practitioners have some sense of disease patterns, costs, and benefits—not just for individual patients but for the entire cohort of patients and, when a practice is the major provider of care in an area, for the community as a whole.

Professor Barbara Starfield’s internationally acclaimed research provides the evidence of how successfully primary care has delivered care and improved the health of people. Dr Julian Tudor Hart provided early practical evidence of implementation with a clear philosophical underpinning of population health improvement in a GP population in a very disadvantaged community.

Underpinning all is the public health contribution of mainstream list based general practice from prevention advice, early diagnosis and treatment eg services for vaccination and immunisation, cervical cytology screening and improving the health of those who have a long term condition. There is also a public health component often understated, of the individual clinical consultation, the basis of ‘make every contact count’. ‘Personal health services have a relatively greater impact on severity (including death) than on incidence. As inequities in severity of health problems (including disability, death, and co-morbidity) are even greater than are inequities in incidence of health problems, appropriate health services have a major role to play in reducing inequities in health’

The overarching priority for health and wellbeing is to enhance social capital, community solidarity, resilience and sustainable development for individuals and communities. All the formal organisations within a geography contribute to social capital, only a minority engage in a wider contribution to health and wellbeing and rarely receive extra support. Can that change? And individual professionals who have ongoing contact with individuals within a community are an important source of enhancing the resilience of the individuals they serve.

Primary Care does not have to do it all. In areas beyond clinical practice where understandably it may lack the capacity or capability, it can engage with others who are best able. Primary Care Networks must be given time to develop or they will be crushed but a future primary care anchor organisation being of its community can offer much.

Anonymous says:
Nov 18, 2020 08:53 AM

Totally agree-logic of closer working between public health provider services and primary care especially stronger integration of MECC approach