GENERALISM AT THE CENTRE OF CARE
There is, it seems, a continuing need to make and re-make the argument that a strong, generalist primary care sector is an essential part of any effective healthcare system. Governments tend to equate investment in health with opening hospitals and buying high-tech equipment. This issue of the BJGP highlights and celebrates many facets of primary care and its engagement with the public health.
Starting at the sharp end, Haj-Hassan and colleagues' study from Oxford (page 171) itemises the key, early ‘red flag’ symptoms found in children with meningitis – leg pain, confusion, neck pain or stiffness, and photophobia are the cardinal symptoms, whereas pallor, headache, and cool peripheries are non-discriminatory. Khan and co-workers' study (page 197) is another reminder of the role of general practice in dealing with serious illness, in this case cancer: survivors of breast, colon, and prostate cancer consult their GPs up to three times more frequently than controls, with implication for both workload and training.
The interface between general practice and public health has always been an interesting one, and is likely to change again in the UK following the publication of Healthy Lives, Healthy People. Steve Gillam provides a trenchant critique of this important area of policy and practice (page 169), while Graham Watt, grappling with general practice at the deep end, sees the pay-offs from investing in health improvement as accumulating gradually over time, like compound interest (page 228). Garrett and colleagues, reporting from New Zealand (page 212), demonstrate the cost-effectiveness of physical activity interventions, even over a 12-month period. Neilson and Walker's study from Glasgow (page 173) strongly suggests that screening for testicular descent in older boys should be re-instated.
Schieber and colleagues from France (page 178) sound a note of caution in the health promotion arena, however. Studying patients' and doctors' accounts of consultations involving cardiovascular risk management, they identified significant mismatches in understanding between them, particularly in relation to advice about nutrition and exercise. They recommend taking care to think about patients' social context, and Watt makes the same point about context in discussing the need for more flexible and imaginative approaches than ‘health checks’ when working in areas of deprivation and difficulty. Rather similar challenges are presented to GPs when faced with decisions about certification of long-term sickness and incapacity. The NICE guidance provides some helpful pointers but Gabbay's group points out the need for more research evidence to inform these decisions, and for better collection of data about work ability along with its greater use as an outcome measure in trials of interventions (page 206).
Two articles discuss the health of children and young people in the wake of the Kennedy report on the cultural barriers to providing good care for them, and the Royal College of General Practitioners' Child Health Strategy. Mathers and Harnden (page 165) recommend more training and a stronger clinical focus on child health, perhaps something to consider in relation to extending the training period for GPs in the UK – which differs from a number of other countries where the care of children is as much, or more, the province of paediatricians as of GPs. Jane Roberts was struck by the success of Kid's Company, a charity for children living in fragile and difficult circumstances, and this perhaps is another vision of how multidisciplinary primary care needs to be to respond to everything that is thrown at it (page 227).
The identity and attributes of the future GP – tomorrow's generalist – are examined from two very different perspectives. Lakhani's James Mackenzie lecture (page 218) gives us an optimistic and inspiring vision of the future GP, who has evolved out of the best of present-day practice, working in an organisation in which integration – clinical, academic, and informational – is the watchword and where professional autonomy has survived. Greenhalgh and Wong (page 166) use revalidation as the mirror, and see over-regulation, a mechanistic medical model, and the rhetoric of managerialism as the threats to the ‘good doctor’ – someone in whom experience and knowledge, wisdom and understanding, and a conscientious professionalism are brought together in the care of patients and populations.
- © British Journal of General Practice, January 2011