Genetics

July 2014

Professional

General practice and public health: who is my patient?

Volume 43, No.7, July 2014 Pages 483-486

Gillian Porter

Grant Blashki

Nathan Grills

Background

General practitioners (GPs) tend to focus most of their energies on providing primary healthcare to individuals, with less attention to the overall population health issues in their community. In contrast, public health practitioners tend to focus on the health needs of entire populations, by addressing the social determinants of health, with less attention to individual patient care.

Objective/s

This article seeks to provide a practical approach for GPs to incorporate a public health perspective in their everyday work.

Discussion

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 healthcare is an important part of modern general practice.

‘Our patients can reasonably expect to have their immediate medical needs attended to, along with an examination of broader issues which may have led to their presentation. It follows logically that family physicians must have a role in looking beyond illness, and trying to shape behavioural, societal and environmental influences on ill health’.1

General practitioners (GPs) have traditionally focused on providing primary care to individuals who present to their medical practice with various illnesses. This patient-centric approach has its philosophical underpinnings in a biomedical view of disease that emphasises an individual focus. Public health on the other hand focuses on the health of the entire population and is underpinned by addressing the social determinants of health. Such a model tends to privilege the needs of the population over the needs of the individual.

Of course, focusing on individual care does not preclude also being committed to a public health mindset; in fact, they are usually congruent objectives. In this paper, we argue that now more than ever, adopting a population perspective to healthcare is an important part of modern general practice and we seek to provide a practical approach for GPs to incorporate a public health perspective in their day-to-day work. We suggest that encouraging GPs to be more involved in the population aspects of public health will require a shift in the culture of general practice in addition to the re-orientation of the incentives.

The traditional model of general practice (individual)

According to The Royal Australian College of General Practitioners (RACGP), general practice is ‘the provision of patient-centered, continuing comprehensive, coordinated primary care to individuals, families and communities’2 (emphasis own). Yet, it is probably true that despite the inclusion of ‘communities’ in this definition, in reality most GPs focus most of their energies on providing direct clinical care to individuals who seek medical advice.3 In countries such as Australia, the fee-for-service funding model has encouraged this focus, with GPs having limited funded time available to participate in any work outside of direct individual patient care.4 Involvement in community level activities has traditionally been a voluntary contribution by altruistic GPs or perhaps, more recently, facilitated through organisations such as the Medicare Locals. In recent years there have been some exceptions to this rule, with Medicare practice incentive payments encouraging doctors to utilise individual patient interactions to promote public health aims. For example, in return for incentive payments, GPs have helped increase child immunisation rates, thus contributing to the population level protection against infectious diseases.5 Furthermore, chronic disease management plans, cancer screening programs and mandatory notification of infectious diseases all represent opportunities for GPs to contribute to public health through their regular practice. Yet, the vast majority of funding in general practice remains dependent on providing curative individual services; thus, there is little incentive for population-level public health strategies to be implemented by GPs. Training models have also reflected the primacy of individual curative care, with examinations testing a candidate’s understanding of the biomedical determinants of disease and their ability to assess, diagnose and manage individual patients6 rather than assess the implementation of population health interventions.

As a result, it is not surprising that GPs dedicate most of their time to providing one-on-one curative healthcare and tend to give little attention to the fact that the health of an individual patient is usually dependent on the overall health of their community. Often this is due to the opportunity cost of undertaking unpaid community level health initiatives at the expense of seeing individual patients. Regrettably, it is often in the areas where public health interventions are most needed (rural and remote regions or lower SES regions) that GPs are most overloaded with individual patient care.

The reality of modern general practice in Australia, where patients come to a GP’s rooms for treatment, and house calls are diminishing, means that GPs rarely observe their patients’ life circumstances. The social and environmental determinants underlying a patient’s condition, which are well established to be the drivers of a population’s health status, may go unnoticed by GPs who are confined to the consultation room. Furthermore, the culture of general practice has become one of strong advocacy for the patient sitting in the examination room over and above thinking about the population health implications of the treatment plan commenced. For example, most GPs will fervently advocate for the earliest possible specialist appointment in the public health system without giving much thought to public health resource or triage implications.

What is a public health perspective?

Population or public health focuses on the health needs of an entire population as outlined by the World Health Organization:

‘Public health refers to all organized measures (whether public or private) to prevent disease, promote health and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases. Thus, public health is concerned with the total system …’7

Public health then is important in promoting healthy communities and, by definition, focuses on the health of the population rather than individuals. Historically, it has included advances ranging from sanitation and housing through to infection control and immunisation programs.

As defined, public health has a particular concern with improving ‘the conditions in which people can be healthy’ or what are known as the social determinants of health.4 These approaches are likely to benefit the population as a whole.8 The underlying social conditions, considered throughout the lifespan, determine the health of individuals and communities. They include a combination of economic stability, education, social and community context, accessibility of healthcare services and environmental factors. When medical practitioners do not consider and address these root-causes of ill health, they simply put out spot fires and ignore the real firestorm. Importantly, communities need to be empowered to take control of their own environments and alter them in accordance with what is best for them, moving the locus of control away from distant external bodies (eg. government and policymakers) and closer to communities.

Public health issues in general practice

In Australia, public health measures have been left largely to the policymakers, for example, town planners and architects, usually with little, if any, input from GPs. While it is easy to propose that GPs should be more involved in public health, it is fair to ask where does the role of the GP stop? Many public health issues may not require the expertise of a GP. For example, water sanitation may well be better left to water engineers, and health promotion advertisements left to marketing experts. However, GPs do bring a wealth of experience and intimate knowledge of their patients and do have a valuable role in informing those public health initiatives that will have bearing on the health of their patients.

While not necessarily understood as population health measures, many activities of GPs already contribute to public health. For example, activities within individual consultations may include one-on-one prevention and health promotion and GPs are often at the forefront of risk factor screening and management.9 There are also various funded GP items (eg. care plans, mental health plans, check-ups for people aged 45–49 years) that incorporate significant preventive elements.9 Therefore, one approach for GPs to promote public health and contribute to the health of their local population more widely is to incorporate a public health perspective in each individual patient consultation. These individual focused activities, when taken across the entire health system, are critical in supporting a system that promotes population health.

However, there are also areas where GPs can more directly engage with communities to influence population health. The World Health Organization’s Alma-Ata Declaration on primary healthcare provides a helpful model for primary healthcare services to achieve universal access to health. Primary healthcare is seen as central to integrating all levels of the health sector as well as encouraging an inter-sectorial approach, social justice, community participation and empowerment. On the basis of the Alma-Ata Declaration, Neuwelt identifies three population health principles that primary healthcare services can put into practice: equitable access, involvement of communities in decision-making and understanding of social determinants of health.10,11

Equitable access

One of the aims of primary healthcare is health equity.11 GPs can work towards health equity in their community by allowing those who need services to be prioritised, seeking ways to provide preventive services to those who may not usually be able to access them and utilising recommended treatment guidelines appropriate to individual patients to steward scarce resources. There may also be room for GPs to work with their local community to develop systems that allow those in most need to access health services more easily, for example, through a graduated fee structure.

Involvement of communities in decision-making

The Alma-Ata declaration seeks full community participation in primary health services. GPs can move towards this through ongoing discussions with local community leaders and members around strategies to promote health and improve services in the local community. One innovative approach has been the Aboriginal Community Controlled Health Services in Australia. These health services, which have local leadership and ownership, seek to holistically transform the health of their communities through providing a wide range of integrated services to and for their own communities.12 There may well be lessons from this model for mainstream health services on how to more fully incorporate the perspectives and preferences of health consumers.

Understanding social determinants of health

The most achievable step forward for GPs in improving their public health practice is to seek to understand the background context to an individual’s life when approaching their healthcare.10 Referrals can be made not just to specialist medical practitioners but to community services that may help to address the underlying social determinants of their ill health. Examples may include referral to financial counselling, social workers or public housing officers.

Many patient presentations to GPs involve issues that are influenced by the upstream social determinants of health for that particular patient. For example, smoking, obesity, inactivity, and drug and alcohol abuse often have underlying environmental, social or physical factors that result in the ongoing risky health behaviour by an individual patient. As GPs are the respected guardians of health in our community, their input can have a significant impact on policies and activities that affect the social determinants of health. GPs are in a prime position to undertake public health advocacy, conduct community education activities, influence policymaking dialogues at a local level, and provide representation at local stakeholder meetings about issues that affect health. In effect, GPs need to be leaders in empowering their communities to take an active control over their health and the environmental factors that influence their health. For example, GPs might challenge and support their community to consider finding new ways to access healthy food sources (eg. community gardens) or advocate with their community for accessible exercise options (eg. bike paths and running tracks). Table 1 outlines some further suggestions for ways in which public health could be incorporated into general practice.

Table 1. Practical recommendations for further GP engagement with public health
1) In routine care
Include the individual, patient-centred activities that have an impact on the health of the community more broadly (eg. reporting notifiable diseases, immunisation, undertaking health promotion and health education and addressing relevant social determinants).
2) Engage with local community health promotion
At the local level, this might involve speaking at community forums, initiating preventve health campaigns or engaging with schools and community groups around relevant health issues.
3) Contribute to public health debate in the media
GPs can raise public health issues in the mainstream media, medical journals and other professional literature.
4) Publish patient education health materials that are locally relevant
GPs can develop locally relevant patient education materials that address key local health issues (eg. smoking, inactivity, air pollution or STI testing).
5) Enrol in membership/advocacy organisations that have an impact on public health
For example, the RACGP, the Public Health Association of Australia (PHAA) and the Australian Medical Association (AMA) all have powerful voices in the public health arena.
6) Broaden GP training
We need to train GPs to understand, value and feel capable of being involved in public health practice. This might include training on the basic principles of public health as well as training in media, presentation, community engagement, and policy advocacy. Such skills would better equip GPs to engage with their local communities in leadership roles, health promotion and advocacy.
7) Support incentives for GPs to promote public health
If funding were available for public health interventions, then it would encourage GPs to be involved in such activities alongside their face-to-face clinical work.
8) Simplify Medicare preventive health incentive programs
Maximise GP uptake of preventative programs with minimal red tape.
9) Special interest groups
Encourage GPs to consider population health as a possible special interest group, for example, in the professional colleges.

Conclusion

GPs should be aware that they have an important role in public health, not only through individual patient care but also through engaging with public health issues at a community and global level. While system-wide change both culturally and organisationally will be required to support increased GP engagement in public health in the future, there are many ways that GPs can incorporate the principles of public health within our existing Australian context.

Competing interests: None.
Provenance and peer review: Not commissioned; externally peer reviewed.

References

  1. Weller, D. Family medicine should focus on the sick: Negative position. Ideological debates in family medicine. New York: Nova Biomedical Books, 2007.
  2. The Royal Australian College of General Practitioners. Standards for general practices. 4th edn. Melbourne: RACGP, 2010.
  3. McWhinney IR. Primary care: core values. Core values in a changing world. BMJ 1998;316:1807–09.
  4. Fraser J. Population and public health in Australian general practice – changes, challenges and opportunities. Aust Fam Physician 2005;34:177–79.
  5. Australian Government. Practice Incentives Program. Medicare 2012. Available at www.medicareaustralia.gov.au/ provider/incentives/ pip/index.jsp [Accessed 6 May 2013].
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  7. World Health Organization. Public Health. World Health Organisation, 2013. Available at www.who.int/trade/ glossary/story076/en [Accessed 6 May 2013].
  8. Wilkinson RG, Pickett K. The spirit level: why greater equality makes societies stronger. New York: Bloomsbury Press, 2010.
  9. Fry D, Furler J. General practice, primary health care and population health interface. In: Pegram R ed. General Practice in Australia Canberra: General Practice Branch, Department of Health and Aged Care; 2000;385–427.
  10. Neuwelt P, Matheson D, Arroll B, et al. Putting population health into practice through primary health care. N Z Med J 2009;122:98–104.
  11. World Health Organization. Declaration of Alma-Ata. Alma Ata. USSR: WHO; 1978. Available at www.euro.who.int/_ _data/assets/pdf_file/0009/113877/ E93944.pdf [Accessed 12 May 2014].
  12. NACCHO. National Aboriginal Controlled Community Health Organisation: Vision and Principles. National Aboriginal Controlled Community Health Organisation, 2012. Available at: www.naccho.org.au/ about-us/vision-and-principle [Accessed 22 January 2014].

Correspondence afp@racgp.org.au

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