Primary care transformation

Studies have shown that regions with a higher ratio of primary care physician to population have better health outcomes

Primary care transformation

Has the pandemic led to an increase in the demand for primary care clinicians? Has Covid-19 unmasked dysfunctions of our healthcare system? Unquestionably yes. We see countless hospital admissions on daily basis due to cardiovascular diseases, cancers, malnutrition, and a huge influx of preventable diseases: dog bites, multi-drug resistant TB, XDR salmonella (extensively drug-resistant typhoid), dengue, hepatitis-B and -C and HIV in both adults and children.

Access to healthcare services is a major concern. Access to healthcare requires health insurance, having competent and qualified work force, medical care services and timely delivery of care (Healthy people 2020).

Covering the population for a core set of services includes consultation with doctors and specialists, tests and examinations and procedures (surgical) ( requires a robust healthcare system with expanded roles for family physicians or general practitioners (GPs).

In order to bring about this change, the health master plan must include the entry point into comprehensive care, i.e. primary care. The foundations of a patient-centred healthcare system need to be laid. Our physicians need to be aligned with the concept of patient-centric care rather than traditional patient care practices.

Since the primary care practitioners will have an influence on patients’ healthcare choices, we must focus on getting this starting point right and adapt to the changing situation. The evolving role and professionalisation of family physicians (GPs) will translate into greater patient satisfaction and better healthcare facilities.

Keeping in view the above, elucidation of what constitutes general practice is of prime importance. Imagine a high proportion of population presenting with an ill-defined problem. Is the system prepared to deal with such a situation?

The first and foremost need is a patient-doctor interaction, the channel through which history-taking, including checking for danger signs, diagnosis and management of patient together with dealing with uncertainty and safety-netting advice occurs. This is the core of general practice.

This interconnection is based on a number of things: focused 10-minute consultation by a trained primary care physician (family physician/ general practitioner), evidence-informed decision at the point of care and making decisions in the best interest of the patient.

Decision making in general practice can be complex, therefore, reliable information from published literature/research or guidelines help address unanswered questions.

Although clinical experience is a key component of decision-making, excessive dependence on clinical experience can misguide the physician (EBP in primary care, BMJ books). General physicians’ adherence to evidence-based guidelines brings uniformity in the qualities of healthcare services across the country. Furthermore, continuity of care is linked to the quality of care, a team-based approach and reduces fragmentation of care.

To build a strong foundation for the success of this discipline, the undergraduate curricula of medical colleges must include a undergraduate family medicine curriculum taught by family physicians with particular focus on communication skills and medical ethics (RCGP, SAPC document, UK).

In terms of service delivery, a multi-faceted strategy involving not only upgrade of existing primary care facilities but also creation of primary care out-patient (OP) clinics (family medicine/ general practice) within secondary or tertiary care facilities and linking dispensaries, basic health units (BHUs) and rural health centres (RHCs) will optimise healthcare services.

Besides reducing unnecessary burden on hospital-based specialists, these family medicine OP clinics will help modify the triage systems at our secondary and tertiary health facilities with the inflow of over 5,000 patients per day. Such reforms subsequently have a wider impact on the day-to-day running of a number of services. Furthermore, development of primary care networks to effectively contain chronic diseases within primary care can be a cost- effective option.

Remote consultations during Covid-19 pandemic using live video, audio and instant messaging with patients have helped address inequality among many other issues. It has changed the dichotomous questioning (i.e. answers in yes or no) and paved the way for change. This could be the much needed post-Covid revolution. Digital healthcare must not be neglected but rather integrated in future models of primary healthcare.

Finally, there is no question that being a GP and surviving in a taxing environment requires resilience. Patient advocacy coupled with leading multi-disciplinary community-based initiatives requires skills that can only be acquired through engaging in certain learning activities.

This responsibility does not rest with teachers/trainers alone. Undeniably, a comprehensive understanding at all levels is needed to promote this specialty which has a unique position in any healthcare system. Studies have shown that regions with a higher ratio of primary care physician to population have better health outcomes (Barbara Starfield, 2005). At a juncture of implementation of primary care policy, the representatives should not just talk the talk but back up the words with an action, too.

The writer is an Assistant Professor in family medicine at the University of Health Sciences Lahore

Primary care transformation