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Last month I attended the Primary Care Partnership Conference, where renowned national and international speakers repeatedly informed delegates that chronic disease and multi-morbidity were best managed in the community, rather than in secondary care.
The referenced research indicated that this was associated with decreased hospital admission rates, earlier patient discharge rates, a reduction in polypharmacy, less likelihood of over-diagnosis, over-investigation, over-treatment and medical error. A win-win situation for patients, doctors, policy-advisors and budget-holders. Except for one small problem. Primary care, in its current state, does not have the capacity to take on this additional work-load.
We also learned at the conference that there is a shortage of community physiotherapists, occupational therapists, psychologists, dietitians, nurses and of course, general practitioners. So, while directing this work to primary care has the potential to favourably influence clinical and cost outcomes, it cannot happen without a concomitant increase in necessary manpower and resources.
While waiting for these resources to be put in place, perhaps we should also consider the potential adverse outcomes of asking primary care, particularly GPs, to take on this additional work, even if adequately planned and funded. Perhaps we should ask ourselves what work is currently being carried out in general practice. Is it of value? Will it be displaced by the addition of new responsibilities, roles and tasks? Will there be unintended losses for patients and doctors that will not be measurable in financial or numerical terms?
Dr Iona Heath, OBE, a London-based GP and ex-President of the Royal College of General Practitioners, in her essay The Mystery of General Practice, suggests that GPs have two key roles: The first is “interpreter and guardian at the interface between illness and disease”. The second is as “a witness to the human experience of, and search for meaning in, both illness and disease”. She defines illness as the experience of malfunctioning of the body. Disease, she explains, is an objective entity, which exposes patients to the benefits and risks of medical interventions. “Illness is what the patient has on their way to see the doctor and a disease is what they have on the way home,” she says.
The first role – the interpreter and guardian at the interface between illness and disease – is easily explained and justified. Patients attend the doctor with what they consider ‘illness’. The doctor then translates this into disease or non-disease. GPs deal effectively with 90 per cent of the problems that present to them. Many of these problems involve people who are distressed, ill or both, but who do not have disease. The doctor listens, examines and explains what he or she understands is happening for the patient and makes a shared follow-up plan.
The doctor acts as gatekeeper to expensive secondary care and protects the patient from over-diagnosis, unnecessary investigation and treatment. This valuable role and function improves quality-of-life for patients and reduces potential healthcare costs, but will never show up as a statistic, will never be visible to policy-makers or budget-holders, its value sometimes not even discernible to doctor or patient. Yet this is one of the main reasons that investing in general practice makes sense.
The second key role of a GP – witness to the human experience of, and search for meaning in, both illness and disease – is more difficult to justify quantitatively. It involves the careful witnessing of illness and disease in individuals, the easing of suffering when cure is not possible. How is this measured? As John Berger wrote in A Fortunate Man, a book that describes a country doctor’s contribution to the community he served, “A doctor who has passed the stage of selling cures, either directly to the patient or through the agency of a state service, is un-assessable.”
How we ‘manage’ chronic disease is as much about easing loneliness as measuring glycosylated haemoglobin or cholesterol. But how do we put a value on these complex doctor-patient encounters? How do we measure and reward the amount of trust earned, the invisible, intangible effect of continuous care by a committed doctor who is competent to know the difference between illness and disease and can tailor his or her treatment accordingly? How do we make sure that as well as ticking the ‘foot review’, ‘retinopathy screening’ and ‘dietary advice given’ boxes, we disengage from our computer, with its reminders and alerts, and connect with the person rather than the disease? Will this be possible in the new ‘productive and efficient service’ that seems to be inevitably coming our way?
It is up to general practitioners to make explicit the hidden value in general practice and to safeguard our consultations so that they remain an intimate place where patients are allowed and enabled to tell the story of their illnesses and we are allowed and enabled to help them live as well as they can, for as long as they can, with or without disease.