Health systems converging around primary care reform

This report was written by Dr Luke Allen, Academic Clinical Fellow, Oxford’s Department of Primary Care and Research Associate, Green Templeton College.

I had an inkling that general practice (family medicine) was leaving value on the table.

My day job – crudely – entails working out what is wrong with sick people and then trying to get them better. But what if we spent more of our energy on trying to stop people from becoming unwell in the first place? Some conditions are the result of bad luck, like arthritis, injuries, asthma, and many genetic conditions; we can’t do much to prevent these. However, the vast majority of illness are caused by modifiable behaviours and environmental conditions. The Institute of Health Metrics and Evaluation reckon that up to 70% of global death and disability is caused by smoking, alcohol, eating the wrong things, and moving too little.

Of course GPs, practice nurses, and community midwives already spend a good deal of their time chastising smokers and ‘signposting’ patients to slimming world. Increasingly, surgeries are also hiring social prescribers to help patients struggling with debt, inadequate housing, poor mental health; the deeper social determinants of health that shape and constrain behaviours. The issue is that these forays into the non-medical realm are still fairly tokenistic and focus on the unhealthy choices of individuals rather than neighbourhood factors that shape choices.

In my role at the World Health Organization I had heard of other primary care systems in other countries taking a more proactive approach to keeping people well. I decided to spend the summer investigating…

You saw it here first

Think back to the last time you were in a deprived area of a large city. Can you smell the fried chicken? Are you wheezing slightly because of the fumes? Deafened by the noise of traffic? Notice that from where you are stood in the high street you can see two betting shops, three off-licences, seven fast-food shops, but not a single blade of grass, and nowhere that sells fresh fruit and vegetables? Cigarette butts are ground into the uneven pavement. You’re not surprised that rates of smoking, obesity, and binge drinking are higher here than the leafy suburbs of your own university town. If we stepped into the local GP practice you would probably find a dedicated but exhausted team that is picking up the biomedical consequences of living in a deprived obesogenic area. The GPs here have an intimate understanding of the local issues that cause disease in their patients, but they don’t have the resources or expertise to do anything.

For three sites – in Ghent, Belgium, and New York’s Brooklyn and the Bronx – the sights, smells, and demographic makeup are strikingly similar, with immigration, poverty, housing insecurity, and high rates of premature mortality. However the primary care teams in these areas have decided to leave the familiar lowlands of one-to-one clinical care to engage with population-level social action. Ghent’s community health centres – pioneered by Jan de Maesenner – have been employing community health workers for decades. They liaise with the practice staff, patients, and local community organisations to develop a ‘community diagnosis’ of the social issues that are driving disease. They then take these issues to local government, health boards, and other health and social organisations who have the power to make changes. They have lobbied for new playgrounds and redesigned road sections to combat childhood obesity and road traffic incidents respectively. And why not? These non-medical issues directly affect health. GPs hold responsibility for the health of the local community, so they should be engaged with issues that drive their workload and patient outcomes.

Brooklyn’s Cityblock health is a new start-up in the same tradition. The primary care provider co-locates medical and social services in their ‘neighbourhood hub’ and employs a ‘community health partner’ to lobby city hall and organise the community around social issues. North of Manhattan, the Montefiore Health System has several decades of experience delivering population-level social interventions alongside traditional medical practice. One intervention to combat joblessness and the lack of healthy foods saw the group establish a network of fruit and vegetable street-side stalls. They are stocked by local farmers, staffed by disadvantaged locals, and sell fruit and vegetables at very affordable prices.

In each organisation, the leaders recognised that they had skin in the game when it came to the local structural determinants of health. All three are paid a set sum to provide care for each patient on their books (‘capitated’ payment) so they also have a financial interest in keeping people away from the doctor. Some of the first forms of this proactive prevention-oriented working were actually pioneered in in Yorkshire by William Pickles and in the Welsh valleys by Julian Tudor Hart – giants of British general practice. The NHS is in desperate need of new models of care to help control spiralling costs and multi-morbidity: international experiences provide helpful case studies but the underlying values were home-grown. We would do well to learn from our own past in order to safeguard our future.

An international convergence

The issues facing the NHS are by no means unique. Ministers have recently signed up to Sustainable Development Goal 3 (health), the Declaration of Astana, and the political declaration of the UN High Level Meeting on NCDs. All three require radical shifts towards population-level primary prevention. There is a growing awareness that primary care provides the apposite platform for delivering on these commitments. In response, the WHO is increasing capacity around the theme of integrating public health and primary care, and has highlighted the work of Ghent’s Jan De Maeseneer in the Astana programme. The UK is slightly behind the curve here, with plenty of work on social determinants at the individual level, but weak leadership around changing the social determinants.

Our GPs are well placed to lead in this area. We already have capitation, listed populations, comparatively good links with public health, and experience delivering preventive interventions. It’s time to make the most of this nascent potential.