Today, as primary health care is facing challenges from several aspects, researchers of general practice in various countries have formulated corresponding reform strategy. Based on a comprehensive review of recent papers published in journals of general practice around the world, we outline current threats to primary health care, the possible future reform direction, and the determination of general practitioners (GPs) to assume social responsibility.
- Three threats to general practice
1.1 “Division” of primary health care
Three papers published in the Annals of Family Medicine, the British Journal of General Practice, and Family Medicine and Community Health have highlighted the declining continuity of primary health care in the United States, the United Kingdom and Australia.[1][2][3]
In the United States, the decline in the continuity of primary health care is mainly manifested in the neglect of continuity in resident education, the continuous division and independence of many sub-disciplines (such as hospitalists, sports medicine, maternal and fetal medicine), coupled with economic factors and the impact of society on GPs’ career choices. The traditional integration model for GPs in the United States of staying in the community, home consulting, nursing homes, offices and hospitals since the 1960s is being strongly impacted with the risk of fragmentation. Because of this, both GPs and patients have paid the price. With the weakening contact with families and patients in the community, job satisfaction and sense of belonging of GPs begin to decline, while patients get lower quality medical services with increasing medical costs.[1]
In the UK, this decline in continuity is manifested by the expansion of primary health care and the greater emphasis on the accessibility of primary health care by the National Health System (NHS). In the past, close doctor-patient relationship based on small-scale primary health care teams and stable communities are influenced by population movements, general practices merging into larger ‘super practices’, increasing temporary work for primary health care physicians and personnel, and work pressure, which make it more difficult for patients in the communities to maintain continuous personal contact with the same GP.[2]
Unlike the situation in the United States and the United Kingdom, Professor David G. Legge, in his commentary Striving towards integrated people-centred health services: reflections on the Australian experience, described the problem in the continuity of management and information in the primary health care system in Australia. The division effect of privatization and marketization brought by neoliberal economic policies is creating serious obstacles to the person-centred primary health care services.
The division first occurs between primary health care services funded by governments at all levels, such as the conflict of medical insurance payment between federal and state governments; second, it is manifested between public community health centers and private hospitals and clinics, for example, the difficulty in receiving efficient health care services in public institutions for patients who asked for psychiatric or dental care, while the government lacks the accountability of private hospitals, private specialists and private insurance funds. In addition, GPs often do not have complete specialist information to refer their patients. Due to these splits, Australia’s primary health care system faces enormous challenges in carrying out community health prevention services, especially in social risk factors influencing health.[3]
1.2 “Numbness” in primary health care
According to a commentary entitled OxyContin and the McDonaldization of chronic pain therapy in the USA in January 2019 of FMCH, excessive emphasis has been put on the efficiency of diagnosis and treatment and accounting regulations in the primary health care system of the United States, which force many doctors to be induced voluntarily or involuntarily by performance indicators, using McDonaldized diagnosis and treatment for patients, that is, to pursue super efficiency with a calculable, predictable and controllable thinking of diagnosis and treatment, in order to treat more patients in a safer way in a shorter time.
But this McDonaldization practice will inevitably lead to the weakening of patient-oriented care and services and may even cause a wide range of medical risks. OxyContin, for example, is a potent, steady, durable analgesic that can be easily reimbursed by local insurance companies in the United States. Purdue Pharma, its pharmaceutical manufacturer, has publicly claimed that its addiction rate is less than one percent. Therefore, under the marketing of the drug company, many family doctors would prescribe OxyContin by instinct after identifying the degree of pain in patients through the 10-point Likert scale. They will not carefully consider causes behind the pain and the feasibility of therapy with no drug or non-opioid drugs, but just to ensure the efficacy of diagnosis and treatment and improve patient satisfaction. As a result, the annual number of OxyContin prescriptions in the United States has increased tenfold, from about 670,000 in 1997 to about 6.2 million in 2002, triggering an epidemic crisis of opioid analgesics abuse.[4]
1.3 “Burnout” in primary health care
An article published in the British Journal of General Practice in December 2018 reviewed recent studies on labor shortage of primary health care in the United Kingdom and Europe. In addition, the author of this article interviewed some graduates from the British General Practice Training Program and identified the difficulty of hiring and retaining general practitioners in primary health care in the United Kingdom. These studies have shown that the increasing workload is an important reason for GPs to leave their jobs.[5][6][7]
In a study published in Annals of Family Medicine in January 2019, a survey of 740 GPs and personnel in San Francisco found that 53% of both clinicians and staff reporting burnout, and 30% of clinicians and 41% of staff no longer working in primary care in the same system 2 to 3 years later. It is statistically significant that burnout contributes to turnover among primary care physicians.[8]
This is a vicious circle: the number of new doctors is decreasing and in-service doctors are leaving, while patients’ demand for medical services is increasing. As a result, doctors’ workload is increasing, which leads to GPs’ burnout, which in turn causes doctors to leave their jobs. This vicious circle is putting primary health care system in a state of “chronic blood loss”, losing a large number of GPs.
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References 1 to 8 of 17:
[1] Frey J J. Colluding With the Decline of Continuity[J]. The Annals of Family Medicine, 2018, 16(6): 488-489. DOI: 10.1370/afm.2322
[2] Engamba S A, Steel N, Howe A, et al. Tackling multimorbidity in primary care: is relational continuity the missing ingredient?[J]. Br J Gen Pract, 2019, 69(679): 92-93. DOI: 10.3399/bjgp19X701201
[3] Legge D G. Striving towards integrated people-centred health services: reflections on the Australian experience[J]. Family Medicine and Community Health, 2019, 7(1): e000056. DOI: 10.1136/fmch-2018-000056
[4] Hughes J, Kale N, Day P. OxyContin and the McDonaldization of chronic pain therapy in the USA[J]. Family Medicine and Community Health, 2019, 7(1): e000069. DOI: 10.1136/fmch-2018-000069
[5] Soler J K, Yaman H, Esteva M, et al. Burnout in European family doctors: the EGPRN study[J]. Family practice, 2008, 25(4): 245-265. DOI: 10.1093/fampra/cmn038
[6] Lown M, Lewith G, Simon C, et al. Resilience: what is it, why do we need it, and can it help us?[J]. Br J Gen Pract, 2015, 65(639): e708-e710. DOI: 10.3399/bjgp15X687133.
[7] Simon C, Forde E, Fraser A, et al. What is the root cause of the GP workforce crisis?[J]. Br J Gen Pract, 2018, 68(677): 589-590. DOI: 10.3399/bjgp18X700145.
[8] Willard-Grace R, Knox M, Huang B, et al. Burnout and Health Care Workforce Turnover[J]. The Annals of Family Medicine, 2019, 17(1): 36-41. DOI: 10.1370/afm.2338.