If the seismic natural disasters of the first months of 2011 were a reminder that we remain at the mercy of natural forces, so the recent alarms about infectious diseases, E. coli in Germany and the resurgence of tuberculosis across Europe, are potent reminders that the battle against infectious diseases is far from won — and, of course, needs to be persecuted with even greater energy to stem the relentless death toll exacted in developing countries. In this issue of the BJGP we examine some of the evidence for extending the immunisation of children against influenza, itself a powerful reminder of the vulnerability of populations to epidemic infections. The recent GAVI (Global Alliance for Vaccines and Immunization) conference in London pledged £2.7 billion to support child vaccination in the developing world. In the editorial from Oxford and the three accompanying papers, we tease out some of the societal, parental, and professional factors that may determine present and future rates of offering and accepting vaccination. We are grateful to Professor David Haslam, a former Chair and President of the RCGP, for allowing the use of his own vaccination as our cover image.
Immunisation and institutional responses to the threat of epidemics have enjoyed a mixed press in recent years and the confused response to the E. coli outbreak shows that there are still lessons to learn. Packham and Robinson remind us of the value of working with an effective public health system, and harnessing the expertise of public health specialists in negotiating the difficult terrain of the prevention and treatment of community-based infections is another key contribution that can be made to the health of the public, and to patient safety.
Writing from Christchurch, New Zealand, Les Toop sounds a critical note over the QOF (Quality and Outcomes Framework), the UK's general practice pay-for-performance system, especially in the care of mental health problems. There is, it seems, accumulating evidence that QOF metrics may be inaccurate and that QOF-driven consultations distort patient–doctor interactions and can lead to maladaptive behaviours and de-professionalisation. There is certainly no cause to be complacent about the capability of the QOF arrangements to eradicate health inequalities: the paper by Norbury and colleagues on influenza immunisation, and Simpson and colleagues on the management of hypertension, demonstrate enduring inequalities related to socioeconomic status and age.
Health systems in many developed economies have identified the need for a strong primary care sector to cope with, among other things, the increased burden of chronic disease related to changing demography and medical advances. This has workforce implications, and it isn't clear that we are very good at selling primary care as a career choice to students and recent graduates. The report by Lambert and Goldacre on career preferences gives little comfort, and the situation in the US is much worse. It is of some interest that students from the UK's most recently established medical schools, where there is often more emphasis on community-based education, are more likely to express a first career choice for general practice. Rosenthal and Chana consider the implications for undergraduate medicine and postgraduate training. In parallel with what has been recommended for the future of the NHS, they recognise the central importance of breaking down the barriers between primary and secondary care, and encouraging respectful joint working.
The UK coalition government's listening exercise on the NHS is coming to an end and it seems likely that last year's naïve plans for GP commissioning will metamorphose into a set of more collaborative proposals for the design and delivery of services. Service re-design will be taking place, in part, against the background of a challenging quality improvement agenda for general practice set out in a recent King's Fund report Improving the Quality of Care in General Practice that will be the subject of future discussions in the BJGP.
Finally, we record with great sadness the death of Barbara Starfield, Distinguished Professor of Health Policy and Management at Johns Hopkins University, Baltimore, and one of the most influential researchers into the role of primary care in health services and the determinants of health and health inequalities.
- © British Journal of General Practice, January 2011