The public health role of general practitioners: A UK perspective Stephen Peckham Department of Health Services Research and Policy stephen.peckham@lshtm.ac.uk
Acknowledgements to co-authors/researchers: Dr Alison Hann, Dr Tammy Boyce, Dr Andrew Wallace, Dr Rebecca Rogers, Professor Steve Gillam, Professor Sally Kendall, Dr Kiran Nanchahal Acknowledgements to funders: King s Fund NIHR Service Delivery and Organisation Programme
Outline If general practice isn t public health then what is it? It s not just cure, it s prevention, it s diagnosis, it s the whole lot, so I can t really separate that out in my head. (GP) King s Fund Inquiry on the quality of general practice Scoping review on general practice and public health Practical and conceptual problems
King s Fund Inquiry Review Part of wider review of quality in general practice One of eight domains examined Reported to Inquiry panel Report and other papers on King s Fund website Health promotion review Structured review of the literature Analysis of four areas in depth childhood immunisation, stop smoking, CHD, obesity Expert group discussion Interviews with practice staff
Stop smoking Current practise Quality Cost effectiveness Potential QOF has led to an increase in recording smoking but less than half of all GPs consistently advise patients to stop smoking. 42% believed discussing smoking cessation was too time consuming, 38% believed it was ineffective, 22% reported lacking confidence in their ability to discuss smoking cessation with their patients Quit rates are substantially lower than recording rates. Quit rates double when pharmaco- therapies are used alongside specialist support. However, little is known as to how these are used in general practice and whether guidelines are being followed brief interventions have quit rates of between 10% to 20% and have repeatedly demonstrated their utility and cost-effectiveness, A further 75,000-92,000 of patients per year in England could quit smoking if GPs increased the number of smoking cessation intervention initiatives by 50 per cent, and accompanied them with pharmaco-therapy
Obesity Current practise Quality Cost effectiveness Potential Approaches to the reduction of obesity in general practice are inconsistent and it is not considered a priority by GPs or patients. Most GPs regard obesity, both its treatment and genesis, as largely the responsibility of the patient, and believe that their capacity to effect positive change in their obese patients weight status is seriously limited The QOF obesity indicator is one of only five clinical indicators to achieve the 100% target but its impact on reducing weight has yet to be established. GP practice staff state, particularly in terms of childhood obesity, that they lack the expertise and resources to challenge obesity Commercial slimming services have been found to be more effective in reducing weight than support from GP but have not been found to be cost effective. Health visitor and dietician advice are effective but there is no cost effectiveness data. Studies on the effectiveness and costeffectiveness of exercise initiatives have yet to be carried out. Studies suggest that there is considerable room for GPs in particular to more frequently discuss weight with their overweight patients
Some initial conclusions Suggests we know about many effective interventions but: not always clear why implementation fails little knowledge of who, when and how this is not simply about knowledge mobilisation Need to support the use of best evidence to design and implement public health interventions in general practice General practice, public health practitioners and academics all have the responsibility to work together to improve the evidence base
Scoping Review Scoping study of the role of general practice in health promotion and disease prevention, with particular focus on service delivery and organisation Literature review mapping the state of the literature, and gaps evidence synthesis Interviews with providers selected practices in several areas in England and Wales interviews with local public health services staff
Methods: Real world definitions 20 PCT public health reports 2 from each SHA One rural, one urban Searched for GP, general practice, primary care, skimmed the reports. Made note of diseases discussed in reference to GPs, and well as particular activities mentioned.
Methods: Literature definitions Hand searched 3 journals British Journal of General Practice Health Promotion International Journal of Public Health 1990-2010 (based on 1990 GP contract) Checked keywords of the relevant articles.
Literature search term matrix General Practice 1 family practice/ (59744) 2 primary health care/ (43841) 3 physicians, family/ (14340) 4 physicians, primary care/ (14340) 5 nursing staff/ (14743) 6 community health aides/ (2554) 7 primary care nursing/ (0) 8 community health nursing/ (17305) 9 ((primary or community) adj1 (care or health*)).ti,ab. (76774) 10 ((general or family) adj1 (practice* or practitioner*)).ti,ab. (59577) 11 (gp adj1 (service* or practice* or clinic*)).ti,ab. (714) 12 ((practice or communit*) adj2 nurs*).ti,ab. (20755) 13 health visitor*.ti,ab. (2046) 14 community.jw. (26733) 15 family practice.jw. (13601) 16 (primary adj1 (care or health*)).jw. (5178) 17 (general adj1 (practice or practitioner*)).jw. (11247) Public Health 19 exp Public Health/ (4573141) 20 social medicine/ (3396) 21 public health administration/ (13255) 22 exp Health education/ (119174) 23 health educators/ (136) 24 exp Preventive health services/ (362340) 25 Preventive Medicine/ (9586) 26 exp Health promotion/ (41272) 27 public health*.ti,ab. (91518) 28 ((primary or secondary or tertiary or primordial) adj1 prevent*).ti,ab. (18842) 29 ((disease* or ill*) adj3 (reduc* or prevent*)).ti,ab. (49847) 30 ((health* or intervention*) adj2 (promot* or improve* or educat* or protect* or program*)).ti,ab. (96228) 31 (prevent* adj2 (medicine or activi* or program*)).ti,ab. (24173) 32 (determin* adj2 (health* or disease*)).ti,ab. (10408) 33 education.jw. (49778) 34 public health.jw. (75226) 35 social.jw. (47187) 36 prevent*.jw. (35331)
Practical Challenge #1 In the keyword search, we missed articles that did have a GP or primary care term. Studies of interventions that could be offered by GPs (eg. smoking cessation) but were not done by GPs. These articles did not have a GP term in the keyword list. Partly explains why articles from the hand search did not appear in the literature search. Many of the studies that do involve GPs or GP-based practices are surveys of GP knowledge and attitudes, audits of patient lists, or surveys of patient reactions to services ok for defining problem, patient perspective etc. Partially explains the large number of studies we go that were not relevant to service delivery.
Practical Challenge #2 Terminology is getting more vague as disease states become harder to define: eg. health behaviour, lifestyle management, behaviour modification. Cardiovascular disease, coronary heart disease, coronary risk factors. Scatters related articles under many different keywords. Makes it difficult to quickly find articles on a given topic. Research priorities have changed over time. changes in disease prevalence what s in demand. response to new policies and GP contracts.
Conceptual Challenge #1 Public health is about the health of populations For example, the Cochrane public health page states: The CPHG facilitates the production of systematic reviews of the effects of public health interventions to improve health and other outcomes at the population level, not those targeted at individuals. But almost universally, GPs deal with the health of individuals. How do you decide which individual activities affect health at the population level?
Conceptual Challenge #2 The spectrum of chronic disease has complicated notions of primary, secondary and tertiary prevention. For example: Poor diet Hypertension and high cholesterol Angina Heart Attack Heart Failure Where does disease start? Where does prevention start? For example: What about post-mi management? Where does diabetes self-care fit in?
Conceptual Challenge #3 Where, physically, does general practice end? At the surgery door? With the team based at the surgery? What if we extend out to primary care? Who constitutes a primary care provider?
Policy and Practice Implications In addition to the challenges for our research, the difficulties we ve encountered raise questions for future policy and practice. These questions are particularly important given the changes in the NHS and pubic health system.
Tentative findings Definitions are a real problem for data collection Appears to be a shift towards secondary prevention driven by QOF in UK Quality of practice is variable Attitude of provider and context of delivery are important P4P generally ignores non-physicians Won t necessarily save money review found only 20% of 1500 interventions lowered costs No clear view about targeted, opportunistic or population screening what works best when and with who? Actually we don t know much about how health promotion/ prevention interventions are delivered and organised
Key conclusions The amorphous nature of public health, and the complexity of the primary care setting, presents a particular challenge to public health practice and research. Need broaden the focus to identify and prioritise public health priorities (eg oral health, hearing loss, vision etc) What s important? How to prioritise this? Can we encourage research on service delivery that is actually set in general practice, when GPs and PNs need to be treating patients? Do we need a system that allows GPs and PNs to do more research in their practices?
References King s Fund (2011) Improving the Quality of Care in General Practice http://www.kingsfund.org.uk/publications/gp_inquiry_report.html Boyce T, Peckham S, Hann A and Trenholm S (2010) A Pro-active approach: Health Promotion and Ill-health Prevention http://www.kingsfund.org.uk/current_projects/gp_inquiry/dimensions_ of_care/health_promotion.html Dixon et al (2011) Impact of Quality and Outcomes Framework on health inequalities (Summary of Full report): http://www.kingsfund.org.uk/publications/impact_of_quality.html