The laws of primary care
I have long suspected that the essence of primary care can be boiled down to universal principles, ‘laws’ if you will. Here are mine:
The First Law of Primary Care is that every person should have an allocated clinician. Don’t take my word for this and, if in doubt, turn to Iona Heath. It has been a decade since she wrote her 2008 BMJ article ‘A general practitioner for every person in the world’, in which she made the case that GPs are not simply a luxury for the most privileged nations.1 I would add two important sub-clauses: first, there should be a limit on the number of patients allocated to the clinician; second, patients should have reasonable access to the clinician and continuity of care.
The Second Law of Primary Care is that every allocated and responsible clinician should have some control to develop appropriate clinical services to their population. This is often neglected but it is the cornerstone of high-quality primary care. We’re not just in it for the individual; we’re there for the community as well. As recently as 2012 the RCGP wrote:
‘… true generalists extend their perspective not only to the presenting patient, but also to the wider group of patients or population’.2
Primary care networks
These principles can be applied to just about any primary care system in the world. Try it. It is why, to paraphrase Churchill, the UK partnership model is the worst form of primary care except for all the other forms that have been tried. Moving to a fully salaried workforce or privatising services risks breaking the system. Partnerships can, for the moment, meet the First and Second Law and hold them in a delicate balance.
We’ve flirted with federations and cavorted with CCGs but primary care networks have now sashayed into town. For many, the prospect of another reorganisation is about as welcome as a syphilitic chancre. Some GPs have criticised the immediate problem of clinicians being distracted from frontline services.3 I disagree. We can’t ever meet the Second Law if we have a mindset that the only useful work a GP does is chipping away at the clinical coalface; that if you dare to drop a session and not see patients then you are, somehow, failing in your work. I understand the frustration when the workforce is so depleted, so stretched, but the very best primary care systems need us to be involved. Many individual practices have been too hard-pressed to develop local care — primary care networks may help without losing the essential localism.
Climate change and primary care
The vagaries of public health and commissioning can make your hair throb. There may only be half a dozen people in the country who understand Sustainability and Transformation Plans (STPs). Richard Feynman’s comment on quantum mechanics comes to mind — if you think you understand STPs then you don’t understand STPs.
In this issue Dougal Jeffries writes on David Wallace-Wells’s The Uninhabitable Earth. It’s a visceral book; a literary kick in the guts. The public health impacts of climate change are already trickling in. The full devastating consequences are in the post: heat illness; changing tropical disease patterns; air pollution; forced migration; and the mental health sequelae as societies are disrupted.
Climate change may feel overwhelming but the simplest of principles, the basic tenets of quality primary care, will help us develop services with our communities to face it down. We need to engage with solutions: to change our diets, to reduce our carbon dependence (offering us opportunities to promote physical activity), and to reconfigure services for sustainability.
Climate change demands, terrifyingly, a full-blown reshaping of society but, with the right models and approach, primary care can adapt and deliver.
- © British Journal of General Practice 2019
