General Practice as an essential part of a socially responsible health care system Iona Heath “Primary Care and Family Medicine: Practical Implementation Challenges” 8th June 2009 Holiday Inn, Silom, Bangkok

gift of history specialist/generalist divide

Apothecaries Act 1815 Medical Act 1858

The physician and surgeon retained the hospital but the general practitioner retained the patient. Stevens R. Medical Practice in Modern England. Yale University Press, 1966

In hospitals, the diseases stay and the people come and go; in general practice, the people stay and the diseases come and go.

Power of scientific medicine for both good and harm

A human being is both a subject and an object; Illness is different from disease; Demand is different from need.

A human being is both a subject and an object; Illness is different from disease; Demand is different from need.

- the prevailing commitment to accurate diagnosis of disease - which is the hallmark of the modern physician - turns on the notion that there is a pure disease state which is, ideally, distinct from the patient. Thus, the patient is seen as a kind of “translucent screen” on which the disease is projected. In consequence,... the patient's subjective experiencing of illness is ignored in favor of an objective, quantitative account of a disease state. S. Kay Toombs The meaning of illness: a phenomenological account of the different perspectives of physician and patient., 1993

- individual and closely intimate recognition is required on both a physical and psychological level. John Berger A Fortunate Man, 1967

- the mystery of the individual is precisely what must be put into the facts to make them meaningful. Boris Pasternak Dr Zhivago, 1958

Doctor Patient Subject Object The body as object: gaze of biomedical science; what this patient has in common with other patients (normative monological) The body as subject: what is unique for this person; life context, story and meaning systems (dialogical)

Theory … grows out of particular circumstances and, however abstract, is validated by its power to order them in their full particularity, not by stripping that particularity away. Clifford Geertz Available Light - Anthropological reflections on philosophical topics, 2000

uncertainty

None of us - generalists all, working in an open system of human interaction can afford the luxury of certainty, or even near certainty. Stevens J. Brief encounter. J Roy Coll Gen Pract 1974; 24 : 5-22.

A human being is both a subject and an object; Illness is different from disease; Demand is different from need.

Stressful life experience Illness Disease requiring hospital treatment

Power of scientific medicine for both good and harm

The strength of a country's primary care system was negatively associated with (a) all-cause mortality, (b) all-cause premature mortality, and (c) cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease. Macinko J, Starfield B, Shi L. Health Services Research 2003; 38:

A human being is both a subject and an object; Illness is different from disease; Demand is different from need.

social solidarity

fear

Schwartz LM, Woloshin S. Changing disease definitions: implications for disease prevalence analysis of the Third National Health and Nutrition Examination Survey, 1988– Effective Clinical Practice 1999; 2 :76–85.

32 million more patients Three quarters of the total adult population

need

needs of the individual needs of the population GP

caution doubt frugality

Contemporaneous and time- lagged primary care physician-to- population ratios were significantly associated with lower all-cause mortality, whereas specialty care measures were associated with higher mortality. Shi L, Macinko J, Starfield B, et al. The relationship between primary care, income inequality, and mortality in US States, J Am Board Fam Pract 2003;16:

illness disease

Sustaining generalism: College Teamwork

College: identity and self-confidence equivalent status mutual respect training, education, standards examination set and assessed by generalists

Teamwork: a seamed service interprofessionalism

Primary Care Team general practitioners nurses –practice –home –older people –children and babies midwife pharmacist interpreters social worker money, benefit, employment adviser administrator reception and clerical staff secretaries trainee professionals

- the most fascinating and absorbing and rewarding job in the world. S Taylor Good general practice 1954