This document outlines the role of public health in general practice. It discusses models of primary care delivery, educational challenges, and outlines a research agenda. The key points are: 1) general practitioners have both preventive and managerial public health roles; 2) there are obstacles to realizing the full public health role of GPs, including training and incentives; and 3) new models of primary care are emerging, and research is needed in areas like population health impacts, education, and policy.

1. Public health in
general practice
Steve Gillam
02.11.10

3. Outline
 What do we mean by PH in PC
 Models of primary care
 Educational challenges
 Commissioning and other eastern foibles
 Research agenda

4. 1. Defining the role
 Distinguished from biomedical and
humanist traditions
 Derive from fundamentals : registered
list, generalist role, referral
rights(gatekeeping)
 Delivered by different disciplines
 Historically oppositional

5. Preventive interventions
 Primary
 Healtheducation, behaviour change,
immunisation, welfare benefits advice,
community development
 Secondary
 Opportunistic detection of chronic disease,
screening
 Tertiary
 Chronic disease management

6. High risk individual and population
based strategies for prevention (Rose)
Identify and treat Shift the whole
those beyond a population
threshold for risk distribution of risk
factor factor

7. 2. Defining the model

8. Package Package Elements Cost/person/year
(CMH) (USS, 1990)
Expanded programme on immunization,
Public school health ( including deworming),
$4.2
Health micronutrient supplementation, health
Package education, nutrition, family planning, tobacco
and alcohol control, disease surveillance,
vector control, aids prevention
Short course (DOTS) tuberculosis $7.8
Minimum treatment ($0.6), management of the sick
essential child ($1.6), prenatal and delivery care
clinical ($3.8), family planning and sexually
services transmitted diseases treatment ($1.1),
limited care for other ailments ($0.7)
Total $12

9. QOF Health gains
 Real but modest gains in some areas, e.g. asthma, DM
 No definite improvement in CHD related to QOF
 Better recording in QOF but not untargeted areas
 No improvement in outcomes, except possibly epilepsy
N Engl J Med 2009;361:368-78.

10. Population health and equity
 Inequalities related to deprivation slowly narrowing
 Reductions in age-related differences for CVD/diabetes
 Variable effects for e.g. gender related differences in
CHD
Lancet 2008;
372: 728–36
Dixon, Khachatryan & Boyce. The public health impact, In Gillam & Siriwardena (eds) The
Quality and Outcomes Framework, Radcliffe, Oxford 2010.

11. QOF scores nationally (% total points) and
changes in exception reporting rates 2004-2009

12. QOF balance sheet
 Improved data recording and analysis
 Modest health benefits for individuals and populations
 Narrowing of inequalities in processes of health care
 Opportunity costs contested
 Unintended consequences: on workforce,
professionalism, McDonaldisation
 Re-defined meaning of quality
 Tyranny of evidence

13. Community
Oriented
Primary
Care
The community general
practitioner...
Julian Tudor Hart. A new kind of
doctor. London, Merlin Press 1988.

14. 3. nMRCGP curriculum statement
 GPs have a responsibility for the community in which
they work, which extends beyond the consultation with
an individual patient. The work of family doctors is
determined by the makeup of the community and
therefore they must understand the potentials and
limitations of the community in which they work and its
character in terms of socio-economic and health
features. The GP is in a position to consider many of the
issues and how they interrelate, and the importance of
this within the community. In all societies healthcare
systems are being rationed, and doctors are being
involved in the rationing decisions; they have an ethical
and moral duty to influence health policy in the
community.

15. Capacity building
 Overcoming obstacles
 Political/ideological
 Contractual
 Undergraduate training
 PH in the nMRCGP
 Organisational turbulence
 QOF and the biomedical model
 New models of training

16. Examples of PH related skills
 Health needs assessment
 Technology/options appraisal
 Evidence based health care
 Data interpretation
 Audit
 Health services evaluation
 Strategic development/planning

17. 4. Genealogy of PCBC
 GP Fundholding
 Total purchasing
 Locality purchasing
 Primary Care Groups
 Primary Care Trusts
 Practice Based Commissioning

18. Stages in evolution/development of PBC

19. NHS structure - new

20. Three domains of Public Health

21. 5. The research agenda
Primary care-oriented systems
are associated with
 More preventive interventions
 Better health outcomes
 Greater patient satisfaction
 Reduced costs of health care
 Reduced use of secondary sector

22. Research priorities
 Practice-based research, e.g. meaning of
symptoms, continuity, MUPS, etc
 Population health impact of different models of
PHC
 Educational research in PH/PC
 Planning/service development role
 Policy research – impact of new white papers

23. Summary
 Public health roles in general practice:
preventive and managerial
 Obstacles to be overcome in realising the GP/
PH role
 Implications for GP training
 New models of primary care delivery will emerge
 Multifaceted research agenda