BMJ 2013;347:f7239 doi: 10.1136/bmj.f7239 (Published 9 December 2013)
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Michael Kidd on primary care’s global challenge Michael Kidd, the new leader of a global family doctor organisation, speaks to Tiago Villanueva about the future of primary care Tiago Villanueva editorial registrar BMJ, London WC1H 9JR, UK
In 2008, the World Health Organization’s World Health Report called for the strengthening of primary care and general practice around the world. Since then, many countries have made enormous progress, but the pace of change differs depending on where you are in the world. Many obstacles remain, and the challenges lying ahead are enormous. Undergraduate and postgraduate training standards in general practice vary tremendously, and the recruitment and retention of GPs continue to be a problem in both developed and low and middle income countries. Delivery of care has also changed dramatically, with increasing emphasis being placed on a team and multidisciplinary approach as well as on task substitution. The generalist tradition does not seem to be what it was. I was curious to learn the views of the new top man at the World Organization of Family Doctors (WONCA) as he passed through London.
Michael Kidd is an Australian general practitioner and the executive dean of the faculty of health sciences at Flinders University, Adelaide. He has a track record as an academic GP and researcher, but, as president of WONCA since June, he now has an opportunity to influence general practice and primary care globally. WONCA represents more than half a million family doctors in 130 countries. Kidd tells me that he sees primary healthcare as the “answer to the world’s great healthcare challenges.” He says, “The reasons are really obvious to all of us: we have an increase in chronic diseases (non-communicable diseases) in all parts of the world; we have continuing epidemics of serious infectious diseases, particularly HIV/AIDS, tuberculosis, malaria; and we have a rising awareness of mental health concerns, particularly depression and anxiety in many of our populations. In many countries, infant mortality rates are falling, people are living longer, but as people live longer we get all the challenges of healthcare in aging communities.” He sees signs that the tide is turning in favour of the recognition of the importance of primary care globally. China, for example, wants to train 400 000 GPs by 2020 to counter a “real problem”
where patients see hospital medicine as the best care, even if they risk being subject to overinvestigation and possibly unnecessary tests.
“We have to focus on disease prevention, health promotion, better chronic disease management, earlier detection of serious disease, and treatment. And all this we do through having a strong primary care basis. This is the bread and butter work of GPs around the world,” adds Kidd.
It starts with training
Kidd believes that the attraction of top talent into general practice starts in medical school. This means spending enough time in the community with GP tutors who are good role models, “so that students actually understand about community based healthcare, which is where most healthcare in the UK takes place.” He fears, though, that student’s rewarding experiences at undergraduate level could be eclipsed by a “negative attitude towards general practice that graduates may encounter as interns and as residents.” He says that they often encounter prejudiced views from specialists who have little understanding of how general practice works or of the important work their colleagues are doing in general practice. GP training around the world differs considerably, with some countries such as the UK having sophisticated and well established training programmes while others have no training programme at all. Nevertheless, he sees general practice/family medicine as a specialty in its own right and says that WONCA encourages countries to develop “postgraduate specialty training in general practice after medical school, before people can go into independent practice.” When I asked him whether there should be minimum standards of training globally in general practice he gave the example of the Royal College of General Practitioners’ MRCGP international qualification, which “has taken this country’s standards for general practice education and training to many other countries and assisted many other countries to develop their own training programmes and assisted doctors in those
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BMJ 2013;347:f7239 doi: 10.1136/bmj.f7239 (Published 9 December 2013)
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countries to gain the specialty status which they’ve been lacking.”
Finally, he thinks that it is paramount for GPs to stay up to date and to prove it. The UK has made considerable steps in that direction by introducing compulsory revalidation for all practising doctors, and he thinks that other countries will develop their own systems to suit the local culture. He doesn’t believe that “there’s any evidence to show that one particular way is better than another.”
General practice in BRIC countries But do the world’s emerging nations, such as Brazil, India, and China, see primary care as a priority, and are they investing in it? Kidd thinks so, but each country is doing it differently.
He praises Brazil for being “the great example of how a government has taken meeting the healthcare needs of their communities seriously, and it has done so through primary care, through the establishment of tens of thousands of primary care teams based around experienced GPs working in teams with nurses and community health workers and is now providing care to the entire population.” He is critical of vertical programmes in developing countries, “often supported by external aid,” which on their own “don’t provide comprehensive care to the community.” He advises strengthening the primary care base in these countries, which could then allow the vertical programmes to “work within the established primary care base.” He says that some countries in Africa and Asia that have strengthened their system of primary care “are now acting as mentors for neighbouring countries and providing support where invited and advice on how to strengthen local systems as well.”
Delivery of care General practice around the world is progressively moving towards team based care and towards greater collaboration with hospital doctors and other allied healthcare professionals. But
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one of the most topical debates right now is about task substitution (“who does what tasks?”). He supports nurses carrying out tasks that have long been the remit of GPs provided that they have adequate support and training, and says that, in some cases, they can outperform GPs, “particularly some of the protocol based work in chronic disease management.” He also thinks that GPs are able to take on tasks traditionally carried out by hospital specialists. He gave the examples of the increased role of GPs in the diagnosis and management of depression and anxiety and dementia, and in the management of chronic diseases such as diabetes and heart disease. He highlighted the unique “specialty skills we have as GPs in the management of multimorbidity in our patients, which is often neglected when people go to single discipline outpatient settings.”
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