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COMMUNITY-ORIENTED PRIMARY CARE |
Stephen Gillam is with the Primary Care Programme, King’s Fund, London, England. Alan Schamroth is with the Bounds Green Health Centre, London.
Correspondence: Requests for reprints should be sent to Stephen Gillam, MA, MSc, FRCP, FFPHM, MRCGP, Director, Primary Care Programme, King’s Fund, 11–13 Cavendish Square, London W1G 0AN, England (e-mail: s.gillam{at}kingsfund.org.uk).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONTHE KING’S FUND EXPERIMENTPROMOTING EXPANSIONLOOKING FORWARDPERSONAL MEDICAL SERVICESCONCLUSIONReferences |
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The UK National Health Service has long delivered public health programs through primary care. However, attempts to promote Sidney Kark’s model of community-oriented primary care (COPC), based on general practice populations, have made only limited headway.
Recent policy developments give COPC new resonance. Currently, primary care trusts are assuming responsibility for improving the health of the populations they serve, and personal medical service pilots are tailoring primary care to local needs under local contracts.
COPC has yielded training packages and frameworks that can assist these new organizations in developing public health skills and understanding among a wide range of primary care professionals.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONTHE KING’S FUND EXPERIMENTPROMOTING EXPANSIONLOOKING FORWARDPERSONAL MEDICAL SERVICESCONCLUSIONReferences |
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Despite a predominantly biomedical and humanist focus, general practice in the United Kingdom has long been infused by knowledge and skills traditionally associated with public health medicine.1 The conceptual basis of COPC can be recognized in the writings of Will Pickles describing the use of epidemiology in his rural practice in the 1930s.2 Likewise, the Peckham Pioneer Health Centre, established before the Second World War by G. Scott Williamson and Innes Pearce,3 has been seen as an antecedent. The philosophy of the center involved protecting good health through a combination of individual and family assessment and provision of a supportive environment.4
Throughout the past 30 years, there have been eloquent pleas for closer working relationships between public health and primary care professionals. At one extreme, arguments have advocated the total usurpation of public health doctors’ work by general practitioners.5 Most have envisioned the emergence of a hybrid: the "community general practitioner." Julian Tudor Hart has been the most visible exponent of something akin to Sidney Kark’s COPC in the United Kingdom. In a series of painstaking studies, he demonstrated the impact of "anticipatory" approaches to the management of cardiovascular risk factors on his practice population’s health.6 His practice, located in a Welsh mining village, took responsibility for both community and clinical functions and held itself accountable to the population served through such means as patient committees, annual reports, and meetings. He argued for new alliances between health professionals and patients as "co-producers of health."7
What injected new vigor into these debates in the late 1980s and early 1990s was the reaffirmation of public health following the Acheson report and the Conservative government’s marketoriented reforms. The former sought to redefine and strengthen the discipline of public health medicine after several decades of decline and presaged a major expansion in the public health specialist workforce.8 At the crux of Tory reforms was the introduction of an "internal market" separating the roles of purchasers (health authorities and fund-holding general practitioners) from the roles of health care providers. "Fundholders" could invest savings accrued through more efficient use of secondary care in practice-based services. (Fund-holding general practitioners, generally serving populations of at least 7000 patients, were allocated budgets under the Tories’ internal market for purchase of most elective hospital care, staffing, and coverage of prescribing costs.) As public health doctors sought to develop strategic planning and purchasing functions within health authorities, however, fundholders often dismissed the constraining disciplines of needs assessment and service evaluation.9
With the evolution of the general practitioner’s commissioning role, recognition of the need for new educational models grew. The King’s Fund regarded COPC as one such model and initiated a program with the School of Public Health and Community Medicine of Hadassah Medical College in Jerusalem in 1991 with the following aims: (1) to pilot test the COPC approach at 4 sites, (2) to develop a training package appropriate to the circumstances of the NHS, and (3) to evaluate the COPC model as adapted in the United Kingdom.
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THE KING’S FUND EXPERIMENT |
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TOPABSTRACTINTRODUCTIONTHE KING’S FUND EXPERIMENTPROMOTING EXPANSIONLOOKING FORWARDPERSONAL MEDICAL SERVICESCONCLUSIONReferences |
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The success of the COPC pilot program was considered against normative criteria defined at the outset of the evaluation. While the pilot projects did not realize all of the aspirations of the original participants, significant advances were achieved. Evaluation of the pilot workshops helped in the formulation of the definitive training package, which was successfully field tested.
The workshops provided the participating teams with an illuminating learning experience and helped to develop links with other agencies. Participants were already aware of the need for time, resources, and other forms of ongoing support if they were to further their projects. The teams gained the necessary support (technical, informational, financial) from their local health authorities, although experiences at the 4 sites varied. Teams were able to make community diagnoses and identify problems on which to take action. They expended much energy on detailed problem assessments, and only a few completed comprehensive evaluations.
COPC helped to develop teamwork and interprofessional collaboration; however, the time and energy required to underpin COPC were underestimated. Some teams learned enough about basic epidemiological principles to apply these principles to other problems. Many individuals learned new skills. COPC provided new learning for health authorities, increasing managers’ understanding of primary care. However, few teams came to regard the principles of COPC as central to their way of working. The utilitarian values underpinning COPC are at odds with the traditionally individualistic doctor–patient relationship. Few teams made contact with patients or their representatives at any stage in their projects.
Quantitative evidence of benefits was obtained in all 11 practices (Table 1
). COPC projects yielded limited gains in terms of behavioral risk factor reduction (e.g., smoking cessation); other benefits were more difficult to measure. COPC provided assistance in terms of development of skills in collecting and analyzing health data. As a result of the small size of the practice populations, however, statistically significant changes in most outcome measures were unlikely to be detected for any but common conditions.
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PROMOTING EXPANSION |
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TOPABSTRACTINTRODUCTIONTHE KING’S FUND EXPERIMENTPROMOTING EXPANSIONLOOKING FORWARDPERSONAL MEDICAL SERVICESCONCLUSIONReferences |
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). Primary health care teams varied enormously in terms of how much they achieved. Much depended on the commitment of local leaders who had instinctively internalized COPC principles. These leaders, whether managers in health authorities or general practitioners, were sometimes imaginative in adapting the COPC frameworks—cutting corners if necessary—to suit their purposes and maintain their team’s commitment. Much implementation could be "bolted on" to existing workloads, but more was achieved with dedicated budgets.
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In summary, COPC provided an inclusive set of general principles as the basis for developing new forms of joint learning. The training package was of value to those with an interest in the professional development of many groups of health professionals. If COPC did not provide a radically new way of delivering health services in the United Kingdom, it certainly complemented other initiatives (such as fund-holding and clinical audit) that were producing increased understanding of the factors influencing the health of practice populations and how to address them. The King’s Fund program spawned a number of similar projects across the country. Interest in COPC has reemerged with the continuing evolution of a primary care–led NHS.
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LOOKING FORWARD |
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TOPABSTRACTINTRODUCTIONTHE KING’S FUND EXPERIMENTPROMOTING EXPANSIONLOOKING FORWARDPERSONAL MEDICAL SERVICESCONCLUSIONReferences |
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The major structural change introduced to deliver these policy goals involved the formation of primary care groups, with the expectation that these groups would, in due course, mature into freestanding primary care trusts. The latter have control of unified budgets that bring together for the first time funding for primary care, prescription, hospital, and community services. Primary care groups and trusts were intended to universalize the best aspects of fund-holding. They are expected to undertake 3 principal functions on behalf of their local populations: (1) improving health and addressing health inequalities, (2) developing primary and community health services, and (3) commissioning a range of community and hospital services.
Primary care groups and trusts bring together local providers of primary and community services under a board representing local general practitioners, nurses, the local community, social service agencies, and the health authority. Primary care trusts serve an average population of approximately 180 000 people. They are required to engage the populations they serve in decisionmaking procedures as they take responsibility for setting priorities.
If these organizations are to succeed in their objectives, they need to develop public health capacity and understanding across their constituent practices. Traditionally isolated small-scale general practices are being required to work in collaborative networks. A directive of primary health care teams is that they address the health needs of their population, working with other organizations to promote health and deliver appropriate care. Primary care trusts are being deluged with central directives—but little guidance—as they lead the transition from semiautonomous practice to managed care. They are struggling to make sense of their health improvement role, and they lack public health capacity.13 COPC could provide frameworks with which to develop skills and promote the engagement of clinical staff at the front line.
Primary care groups and trusts have been described as "the essence" of COPC.14 At best, the British primary care reforms can be seen as an uncontrolled, nationwide experiment in the application of COPC methods, but they differ crucially in being introduced from the top down rather than from the bottom up. The COPC model has been developed mainly but not exclusively for underserved populations. Descriptions of outcomes of most COPC initiatives are limited, and COPC methods are time consuming and vulnerable to domination by epidemiological data collection. Too much time is spent on assessing needs and defining population problems and too little on implementing changes in services.
Nevertheless, champions of COPC are continuing to apply their model in the current environment. Attempts have been made to streamline the cycle by simplifying the stages of "community profiling" and "problem definition."15 Readier access to the evidence base on what systemwide interventions are most effective in addressing population health priorities (such as heart disease and teenage pregnancy) would reduce unnecessary duplication in the devising of interventions. If primary care trusts are to develop the vision required to move beyond service planning to address the social determinants of health, they will need all the help they can get.
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PERSONAL MEDICAL SERVICES |
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TOPABSTRACTINTRODUCTIONTHE KING’S FUND EXPERIMENTPROMOTING EXPANSIONLOOKING FORWARDPERSONAL MEDICAL SERVICESCONCLUSIONReferences |
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| COPC in Practice: A Case Study Alan Schamroth’s 5-partner general practice of 11 000 patients in north London was one of the pilot sites involved in the King’s Fund program. Traditionally, there has been little incentive to address population health in UK primary care. Other than for attaining immunization and cervical cytology targets, general practitioners have typically been financially rewarded only for responsive care. Any "needs assessment" is done on the doctors’ own time and at their personal expense. The training program profoundly shifted the team’s thinking on primary care away from demand to unmet needs. COPC provided both the intellectual satisfaction of identifying the health needs of the "whole" practice population and the professional reward of being better able to respond to them. The process of gaining new skills in audit and population data analysis stimulated team building, encouraged self-reflection on current practices, encouraged evidence-based practice, enhanced managerial skills, and strengthened the practice in terms of arguing for resources. COPC provided the theoretical underpinning and tools for new tasks at a time when fund-holding offered the financial wherewithal. Under the PMS model, Alan Schamroth’s COPC activity has increased, and team members view this as an exciting development. The COPC philosophy remains their guide, but they have applied the model flexibly. They seldom adopt a purist approach and have not undertaken another community profile, although in the past 8 years the area has changed both physically and socially. The slow progression through the COPC cycle is no longer perceived as disheartening, in that the team has felt less tightly bound by rigid methodological constraints. The processes of monitoring, surveillance, and evaluation have often been delayed until extra resources have become available. The team is not the huge entity it was under the fund-holding model; as a result, it has become easier to coordinate projects, and team members are more motivated.
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONTHE KING’S FUND EXPERIMENTPROMOTING EXPANSIONLOOKING FORWARDPERSONAL MEDICAL SERVICESCONCLUSIONReferences |
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A recent report on the United Kingdom’s public health workforce highlighted shortages,17 and this has increased pressure to expand public health training across disciplines at both undergraduate and postgraduate levels. COPC modules are already being used in new training programs, for example as part of Internet-based teaching curriculums (see http://www.ucl.ac.uk/MSc). In addition, the proposed University of the NHS (still at the planning stage but envisaged as coordinating the undergraduate training, and possibly postgraduate training as well, of all cadres of NHS staff) would offer potential opportunities for expansion of access to COPC. Last but by no means least, extra government funding for the NHS should provide appropriate financial incentives as well as support for staff and their training.18
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Footnotes |
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Accepted for publication June 28, 2002.
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References |
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TOPABSTRACTINTRODUCTIONTHE KING’S FUND EXPERIMENTPROMOTING EXPANSIONLOOKING FORWARDPERSONAL MEDICAL SERVICESCONCLUSIONReferences |
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2. Pickles W. Epidemiology in Country Practice. Bristol, England: John Wright; 1939.
3. Pearse IH, Crocker LH. The Peckham Experiment. London, England: Allen & Unwin; 1943.
4. Scott-Samuel A. Total Participation, Total Health—The Peckham Health Centre. Edinburgh, Scotland: Scottish Academic Press; 1991.
5. Russell EM. Community medicine and primary care in Scotland. Community Med. 1988;10:112–116.[Medline]
6. Tudor Hart J, Thomas C, Gibbons B, et al. Twenty-five years of audited screening in a socially deprived community. BMJ. 1992;302:1509–1513.
7. Tudor Hart J. A New Kind of Doctor. London, England: Merlin Press; 1988.
8. Acheson D. Public Health in England—The Report of the Committee of the Enquiry Into the Future of the Public Health Function. London, England: Her Majesty’s Stationery Office; 1988.
9. Audit Commission. What the Doctor Ordered: A Study of GP Fundholding in England and Wales. London, England: Her Majesty’s Stationery Office; 1996.
10. Gillam S, Miller R. A Public Health Experiment in Primary Care. London, England: King’s Fund; 1994.
11. Register of Cost-Effectiveness Studies. London, England: Secretary of State for Health, Economics and Operational Research Division; 1994.
12. The New NHS: Modern, Dependable. London, England: Her Majesty’s Stationery Office; 1997.
13. Gillam S, Abbott S, Banks-Smith J. Can primary care groups and trusts improve population health? BMJ. 2001;323:89–92.
14. Bindman A, Weiner J, Majeed A. Primary care groups in the United Kingdom: quality and accountability. Health Aff. 2001;20:132–145.
15. Hooper J, Longworth P. Health Needs Assessment in Primary Health Care. Huddersfield, England: Calderdale and Kirklees Health Authority; 1998.
16. Lewis R, Gillam S, eds. Transforming Primary Care: Personal Medical Services in the New NHS. London, England: King’s Fund; 1999.
17. Secretary of State for Health. The Report of the Chief Medical Officer’s Project to Strengthen the Public Health Function. London, England: Her Majesty’s Stationery Office; 2001.
18. Secretary of State for Health. The NHS Plan: A Plan for Investment. A Plan for Reform. London, England: Her Majesty’s Stationery Office; 2000.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
