General Practice and Public Health, let us arrange a marriage!

General practitioners (GPs) have a patient-centric approach and addresses individual’s presenting needs. On the other hand, public health practitioners focus on health needs of the entire population and focuses on social determinants of health. Although there are a number of overlaps such as immunisations and other maternal and child health services, complete population coverage by GPs is not seen as a priority.

GPs have an important role in public health both through individual patient care and by engaging with public health issues at local, community and global levels. Adopting a population perspective to health care is an important part of modern general practice.[1] Public health specialists possess certain skills that would not only help GPs covering entire population, but also improve the quality of primary health care provided by them. More recent re-emphasis on Primary Health Care (Astana Declaration) and Universal Health Coverage (UHC) makes this collaboration even more significant.

Perhaps general practice (GP) in the UK demonstrates how GP and public Health complements each other. The National Health Service (NHS) bearing the cost of essential health services, provides health care to every citizen through access to primary health care and referrals from GP to secondary care where required. The health visitors (midwife and nurses), who work in the community providing largely maternal and child and other social services. The public health departments are located in each district, headed by a director and a number of consultants, all being public health specialists. Certain amount of collaboration exists among these departments in providing comprehensive primary health care, but generally they operate independently of each other. There is scope of improvement in this collaboration to yield more cost effective and efficient health care.

Julian Tudor Hart in 1991, demonstrated in his practice how whole population care through organised case finding and audit is feasible but only with a labour intensive approach combining accessibility, flexibility, and continuity, as well as a planned and structured approach ….. It may reduce risks for at least some high risk groups …. and that whole population care helps reduce mortality.[2] He demonstrated that proactive continued approach to assess, treat and monitor risk factors for certain chronic diseases, such as blood pressure, obesity, diabetes etc. can reduce morbidity and mortality to some extent. Findings of this work were further corroborated by public health population approach, demonstrating improvements in infant mortality and cardiovascular, respiratory, cancer and external causes of mortality in the practice when compared with the neighbouring practice.[3]

Important factors which made this organised case finding and audit possible was a population approach and not just the patients who came to see him in the practice. He followed each patient in practice population using age-sex register to monitor non-communicable diseases, such as obesity, chronic heart disease, diabetes and some cancers, and provided follow up and care according to their needs.  
Obviously all GPs may not follow this example but a systematic collaboration with public health specialists can make such an approach possible. Not all countries have the same system as in the UK, but primary health care needs public health specialists to assist in the population care to achieve UHC. The Lancet this week carries an editorial, "Ensuring and measuring universality in UHC"[4]. Measuring of UHC at universal level is discussed at the global level, but measuring UHC needs to start at Primary Health Care.

Primary health centres, particularly in rural and remote areas, do have designated villages/communities and often have details of their catchment population (age-sex register). Efforts to provide comprehensive maternal and child health services to the whole population can serve as a starting point to aim for population coverage towards UHC. In particular routine immunisations to all children under two years of age, growth monitoring of all under-fives, antenatal, natal and postnatal care to all women and referral services are already identified priority services but are not systematically coordinated for full population coverage. Premature deaths from Non-communicable Diseases (NCDs), both in developing as well as developed world is of concern. NCDs at Primary Health Care are poorly addressed. Screening and tackling risk factors for these diseases in the population is essential to improve health status of the populations.

One of the major weaknesses of the Primary Health Care, especially in developing countries, is the paucity of information feedback from data collected by these centres. Routine data collection at primary health centres and its transfer to district health offices needs to be analysed and fed back to the primary health centres for review and in service training, leading to improved health services. District hospital activity analysis, which is also collated and sent to central offices, must be used by the health service providers in training and monitoring health. Obstetric and new born data is the first example.

Population approach and using information from routine data are two areas where public health specialists come into the picture and can be of great assistance in improving health service provision and fulfilling the dream of comprehensive primary health care leading to UHC.

Further details and a number of these issues have been discussed earlier in weekly articles and can be found under Home > Old Items.

• Using available data in Primary Health Care (November 17, 2018)
• Defining Universal Health Coverage (December 22, 2018)

References:
[1] Porter G, Blashki G & Grills N. General practice and public health: who is my patient? Australian Family Physician. Vol. 43, 7 Jul 2014.
[2] Hart JT et al. Twenty five years of case finding and audit in socially deprived community. BMJ VOL 302: 22 JUNE 1991.
[3] Kaul. Comment on Twenty five years of case finding and audit. BMJ Vol. 303: 31 Aug 1991.
[4] Ensuring and measuring universality in UHC. The Lancet Vol. 393. January 5, 2019.

Additional support of Public Health in UHC: (9 Jan 2019)
Public health researchers have much to offer to improve the understanding of the local and specific needs of communities. For Robert Verrecchia and colleagues, how UHC relates to public health has not received the consideration it deserves. “Public health advocates will need to do more to promote not only the health benefits of public health interventions but also the economic and political benefits too”. UHC and Public Health. Thelancet.com/public-health Vol 4 January 2019.


General Practice and Public Health: Who is my patient? (Full article - Reference 1)

​Inverse Care Law: The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.          Julian Tudor Hart. Lancet Vol. 297, p405-412, February 27, 1971.

JTH 25 years of case finding and audit  (Full article - Reference 2)
Comment on 25 Yrs of case finding and audit: Kaul BMJ Vol. 303 31 August 1991 p524-5 (Full article- Reference 3) 
Ensuring and measuring universality in UHC (Full article  - Reference 4)
Primary Care and Public Health: Kaul & Rogers BMJ Vol 307 2 October 1993 p866-7 
Evans J, Rogers C and Kaul S. The General Practice Morbidity Database Project Wales - a methodology for primary care data extraction. Medical Informatics. An international journal of information processing in health care. 1997 Volume 22 No. 2 p 191-202.
GPMDB in GP Prescribing Data
Hippocratic Oath