Abstract
The RCGP Junior International Committee (JIC) is aware of the growing hunger among UK GPs to get involved in international primary care. We are a community of AiTs and First5®s aspiring to involve GPs in the discovery of global health matters early in their careers. However, we find ever fewer people need convincing of the immense value and enjoyment this can bring to their work. We are inundated with inquiries about global exchanges, navigating work in the UK with international work, getting involved in research and educational opportunities and numerous requests for signposting to migrant health resources and networks.
I first met Professor Lakhani at the WONCA Europe Conference last year, in Krakow, after his energising speech about the future of general practice. He highlighted international partnerships as a core component of the success and longevity of general practice. I wanted to hear about the College’s current work at an international level. The JIC asked members in a competition for burning questions on global health to put to the College President. The winner, Dr Arnoupe Jhass, an ST4 in London, joined me to quiz Professor Lakhani. We began with his winning question about the Alma-Ata declaration of 1978, an international commitment to ‘Health for All by 2000’ through strengthening primary healthcare systems.
It is very apt that we discuss the Alma-Ata declaration since it is now the 40th anniversary. I know some people think it is unachievable, utopian. Actually, I think it is important for two reasons: First, it talks about universal health coverage and why primary healthcare is important for societies and communities, but it also addresses the wider determinants of health. We know the factors that cause ill health are not necessarily all medical. The declaration implies that to get good health, society needs to be thriving and people need to be able to participate, to fulfil their ambitions and potential in addition to good healthcare.
Health reforms have, as you say, been hijacked by disease-orientated models of care. Worldwide, health systems build bigger hospitals and more specialist tertiary care. However, a good outcome needs a good generalist, a well-informed patient and a good specialist. We must use leadership and evidence to build a coalition of networks. It is the duty of family doctors, to promote the discipline and to protect from over-investigation and over-treatment. GPs are specialists in ‘you’ rather than ‘your conditions’, although we know about these as well, and we must all promote this. More enlightened countries are now moving towards primary healthcare-dominated health systems.
We need general practice on the specialist register. There are moves through the European Union of General Practitioners (UEMO) and other European agencies to achieve this. The MRCGP is a specialist qualification, that’s the legal standard. Even in this country GPs often feel undervalued. Problems with workload or with lack of appreciation by other parts of the system have to be fixed. We have a battle on our hands to convince people of the value of good generalists. Professor Barbara Starfield’s work helps – an academic basis for generalism. The evidence shows that with more family physicians, life expectancy improves, patients are more likely to take their treatment and feel more empowered. Outcomes are better and it is value for money – something really important to governments and taxpayers.
There is some interest in whether we should change the name of the GP to, for example, ‘Consultant in primary care’. I’m not sure. Rebranding does not always work and could devalue a very good title. We want GPs to be the most influential doctors for their patients and if we get everything right, people will be saying ‘Are you a GP or just a consultant?’. I say this tongue-in-cheek! Historically there has always been banter and hierarchy between generalists and specialists. Lord Moran, Winston Churchill’s personal doctor, famously said GPs were ‘doctors who had fallen off the ladder’, this was when we were trying to establish the college in 1952. The ancient medical royal colleges were against the establishment of a college of GPs. We were founded in secret on 17th November 1952, with the help from government and influential people, like Drs John Hunt and Fraser Rose. We now have the largest medical royal college, 52,000 members, a turnover of 56 million pounds, a world-class assessment system, 3250 totally filled training places and a third of practices involved in teaching and training. Further, 90% of the work done in the NHS is done in general practice, with 10% of the funding; 90% of practices are rated good or outstanding, with 90% patient satisfaction. Which other public service gives you that? These are fantastic achievements.
We were the first academy of family medicine; people see us as a parent. As an institution, I do not think we have been strong enough in terms of our international presence and strategies.
We want to build stronger international partnerships. We have a new Clinical Director, Dr Mike Holmes, and a new strategy focused on co-production. We currently have 37 international programmes with an emphasis on developing expertise, education and training. We are also promoting the membership exam. All the main royal colleges already have big established international programmes.
I myself came as a refugee to this country in 1972. We came from Uganda, we were stateless, we had 90 days to leave the country, so I do understand what this question is getting at. In inner-city Leicester, where there is a large migrant population, we have practices with a very high list turnover. Practices struggle because the traditional model measures their outputs in a certain way: QOF, screening, immunisation. On paper it looks like they’re not doing a good job – high prescribing, mental health admissions – when, actually, they’re supporting this vulnerable group.
I think where there are sufficient numbers of people with this need in a locality, we need to think about how to provide a specialist service, perhaps through primary care at scale or a federation with a hub and spoke model. For example, in Leicester we have a practice commissioned to serve the homeless population. There are 30-minute appointments and specially trained staff. The service was rated outstanding by the Care Quality Commission (CQC). However, too much specialisation in family medicine is not a great idea – our richness and outcomes come from being generalists.
I went to Julian’s funeral in Port Talbot, near Glen Corrick, where he used to work. He was definitely a giant in medicine and in general practice. In addition to the inverse care law, he also showed the importance of taking people’s blood pressure opportunistically: He trained as an epidemiologist and collected data that demonstrated a much reduced mortality and morbidity rate if you did this. In fact, tomorrow I am involved in a meeting to see how we can further mark Julian’s work and life.
I am very sad to report that even in 2018, the inverse care law still applies in large parts of the country. Health inequalities I think are widening. Professor Graham Watt has done immense work around ‘deep-end medicine’ in deprived areas of Scotland. What both Julian and Graham have shown is that good general practice is essential, but it’s not a biomedical model necessarily. A lot of social prescribing is needed in addition to addressing the wider determinants of health. There is a high risk of burn-out for GPs because patients do not have the straightforward biomedical problems learned in medical school training.
Ultimately, we need state commitment and policies to address health inequalities. Currently, health service policy does not do this adequately and needs a radical shake-up.
Professional leadership is key. The GP culture of service to communities and high clinical standards is as a result of professional leadership at an organisational and individual level. In the history of general practice there is crisis regularly, but from it emerges a stronger profession and a stronger standard and quality.
Questions from:
Dr Aya Ayoub, GP, London
Dr Arnoupe Jhass, ST4, London
Dr Nathaniel Aspray, ST2, Northumbria
Dr David Blane, GP, Glasgow