Primary care, so we claim, is comprehensive; we try to deal with whatever problems our patients bring. We even point out to learners that this is one of the features to distinguish us from specialists, who are able to define quite clearly the limits of their expertise.
Perhaps that is one of the reasons why registrars express some doubts about taking on the responsibilities of being principals (page 280), and why better careers advice in future may help to ensure that only those who can cope with such a limitless field will opt for a career in general practice (page 246).
However, with no fixed boundaries there will always be problems where the extent of our responsibilities is ill-defined. For instance there has always been a debate about whether alcoholism is or is not a medical problem. The leader on page 247 argues persuasively that it is firmly in the realms of medical primary care, although it also acknowledges that there are limits to what doctors can do on their own. This is worth reading if for no other reason than to destroy any complacency we may retain in the UK that our rates of alcohol-related disease are much lower than those in other European countries.
Then there are the very large numbers of patients with well established medical conditions, but who decide not to consult about their problems (page 269). Do we have a duty to encourage such people to consult, in order to try to help them improve their functioning, or is it better for us to respect their stoicism, and for them to steer clear of doctors?
The latest area where this question arises is domestic violence. This, like some other problems with essentially social origins, causes problems that most would define as medical (page 294) and which are more likely to present to GPs than to anyone else (page 243). Whether that turns it into a general practice problem is still an open question, but it's difficult to argue that we can simply ignore it. One group in the Netherlands has tackled the difficulties of identifying victims of abuse as they present in general practice surgeries, and with spectacular success (page 249).
One might wonder, in passing, why this trial has been so successful, when compared with the many trials attempting the same general approach towards depression.
The study on page 258 reports that most women are quite happy to be asked about domestic violence. However, again as an echo of other areas, the difficulty of too bland an interpretation of these data is shown by the small numbers of women unhappy to be asked about domestic violence, and who were much more likely than the others to have been victims of such violence in the last year.
Then there are groups with even less well defined needs. What is the responsibility of GPs towards asylum seekers (page 306), the homeless (page 286), and those living in deprived areas (page 283)? Some readers will be surprised to read that, despite greater demand for out-of-hours care apparently made by those living in the most deprived areas (page 283), practices working in such areas have performed only slightly worse in QOF scores compared to practices in more affluent areas (page 277). One reason to look at this study is for the scatter plot on page 278. Remember that the Department of Health calculated its liability on the basis of an average QOF achievement of 750 points, which puts in perspective some of the current financial shortfall in the NHS.
The leader on page 244 reminds us that this was a disastrous miscalculation on the part of the Department, especially as we now know that there were substantial improvements in some of the indices in the years preceding the introduction of the QOF. The leader also repeats the concern that the items which are susceptible to some kind of reward payment may crowd out those where there is little or none, and here the study on page 262 offers a questionnaire which might help to even up the balance.
There's quite enough work for us all to do, even without having to watch out for the kind of alarming decision that Julian Tudor Hart reports on page 303. But then, as Curran is credited as saying: ‘The condition on which God has given liberty to man is eternal vigilance’
- © British Journal of General Practice, 2006.
