7 Primary care: potential wealth, actual poverty

Medical science advances faster than social understanding or structure. Family doctors can in theory do far more for their patients in 1994 than in 1912, but in practice the time available to do it has increased very little, and imagination has been correspondingly constrained. Doctors self-employed as entrepreneurs contracting to provide public service preferred to work alone, rather than spend relatively small earnings on more staff. Most of the new and effective techniques developed by medical science required not only more time, but also a larger and more diverse team than community generalists found it economic to provide. Advances in medical science were therefore mainly applied by hospital specialists, not community generalists.

In this common currency of clinical time, salaried or capitation-paid generalists were too poor to use much medical science, except by hasty prescription of the magic bullets promoted by the pharmaceutical industry. Most GPs still work in clinical poverty, where a free tabloid trade magazine paid for by pharmaceutical advertising (Pulse) has more readers and is regarded by more of them as useful, than the British Medical Journal, and MIMS, a prescribing handbook distributed by the pharmaceutical industry, has far more users than the excellently produced and far more authoritative British National Formulary, distributed free by the Department of Health.

Many GPs try to preserve their self-respect by denying this scientific poverty. They deny any need for the academic exactness of teaching hospitals and research centres, boasting that their work is of a more practical, common-sense nature. Patients have common, vulgar diseases, easily subdued by spraying with magic bullets fired from the hip, without pretence of diagnostic accuracy, and still assisted by close human relationships long forgotten in hospitals. These denials deceive nobody. Why endure 8 or 10 years of arduous training, only to end by denying that scientific knowledge is as necessary to solve the most common and important health problems in the community, as it is to solve clinical puzzles in hospitals ?

From an appallingly low base in 1948, NHS GPs generally made remarkable progress in quality of care, often with little interest or assistance from their hospital colleagues, and always with indifference from administration, until the NHS market “reforms” set an entirely new agenda. By the late 1960s, NHS GPs began independently to redefine their role. They became more interested in social and personal problems patients actually had, and less satisfied with merely excluding organic diseases they did not have. Family doctors began to accept much wider clinical responsibilities, and became more selective in their referrals to specialists. New outpatients referred by GPs fell steadily from 302/1,000 population in 1962 to 161/1,000 in 1976. This was followed by a slow rise to 186/1,000 by 1986, still 38% below the 1962 level, and down again to 156/1,000 by 1990. This fall in referrals was accompanied by a steep and sustained rise in GP-initiated laboratory and X-ray investigations, confirming that more clinical responsibility was being accepted by family doctors and their primary care teams.

However, until much larger investments of time, effort and imagination are put into staff and team development to deal with continuing anticipatory care of chronic or recurrent health disorders, a large gap will remain between the minimum clinical standards expected in hospital out-patient departments, and those customary in general practice. This issue has suddenly become urgent because there is now administrative pressure for redeployment of follow-up care from hospital out-patient clinics to primary care teams.


A good example of the size and nature of the problem is care of non-insulin dependent diabetes. A study in Cardiff compared patients with this disorder randomly allocated either to follow-up care by their GP, or to continue attending the hospital clinic. The GPs had agreed to this, and to follow a simple management protocol monitoring important health indicators for diabetics, such as urine tests for protein, tests for blood glucose, and examination of the retina. When both groups were followed up 5 years later, all the patients randomised to their family doctors had been seen, usually several times, but only 14% had been monitored annually according to protocol, compared with 100% of hospital patients. Three times as many of the GP patients had died. Similar studies elsewhere have shown similar figures .

This difference in quality of care has little to do with the competence of specialists compared with GPs. Most routine follow-up work in hospital diabetic clinics is done by junior medical staff in training, not by specialists, and most of these junior doctors go on to become GPs. The real difference is that hospital doctors inherit traditions of team care, with supporting nurses, laboratory and office staff, all of whom contribute to successful running of a clinic, whereas family doctors inherit a tradition of single-handed practice, from which they have only recently moved toward group practice, and even more recently to employment of full office staff and practice nurses. As independent contractors, family doctors must still fund much of their work from their own incomes, whereas in hospital this is a responsibility for administration. Adequate care of diabetics starts (and all too often ends) with a strict checklist of a few essential measurements. Experience shows that in practice these measurements are simply not done, unless clinics are organised for the specific purpose, and non-attenders are actively followed up. To organise such community-based clinics for the first time requires organising skills and imagination which have only recently begun to be taught or even encouraged in our medical schools.

Yet the results even of hospital diabetic care are generally poor compared with what we know to be possible, and mostly inferior to the best that have been achieved by the most innovative community primary care teams. These have usually evolving from systems of shared care, in which follow-up by primary care teams is integrated with the work of a hospital diabetic department. Diabetic care depends above all on well-informed, well- motivated patients, who understand the nature of diabetes, its complications, and how to avoid them, who measure health indicators such as blood or urine glucose levels themselves, set specific targets and check their attainment. They participate as co- producers of their own health, a gain both for themselves and for the community, which then has fewer people to treat for gangrene, blindness, or kidney failure – a social as well as a private product. Obviously all these tasks are potentially better done in the community, where patients look larger and doctors a bit smaller.

This is just one example of a very general shift in the nature of health care. Traditionally, health services everywhere have given priority to crisis intervention, repairing damage after it occurred. This remains the image of medical care favoured by television drama and most exciting to the public. But we can now see that though repairs, where possible, are obviously necessary, a repair system will work most efficiently if underpinned by a much wider system of continuing health maintenance, which can diminish the need for crisis interventions in the first place, and so far as possible ensure that they do not recur, leading to the “revolving door” system familiar in US emergency departments. For example, a brief antismoking programme administered by nurses has been shown to be 500 times more cost-effective, in terms of years of life saved, than coronary bypass graft surgery. Medical science has already developed far enough for us to see real future possibilities of maintaining health in most people continuously, right up to the point where they die a natural and relatively abrupt death.