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Collings report

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aDepartment of General Practice, Medical School, Queen's Medical Centre, Nottingham NG7 2UH

Collings's grim description of postwar general practice in England and his sombre analysis of its prospects created an immediate sensation. In addition to its value as a historical document, the report is also regarded as a turning point in the postwar history of British general practice. The study is also interesting for another reason, which has not been acknowledged: Collings merits recognition as a pioneer of ethnographic research at a time when it was largely unknown elsewhere in British social research.

J S Collings's survey of English general practice was published in the Lancet on 25 March 1950.1 His grim description of postwar general practice and his sombre evaluation of its prospects (box) created an immediate sensation. His report, however, is of more than antiquarian interest. Within British general practice it has acquired semimythical status. It has been acclaimed a "classic report,"2 "the most devastating attack on the image of the family doctor,"3 and "an Exocet fired right through the basis of general practice."4 More positively, it has been hailed as a turning point,5 the single most effective factor in mobilising opinion in favour of constructive change,6 and a seminal contribution to the formation of the Royal College of General Practitioners.7 I will argue that Collings also deserves to be recognised as a pioneer of ethnographic method in British social research.

Origins and publication of the report

The Collings report is unusual in several regards. Firstly, Collings seems an improbable choice as researcher. An Australian, he had previously worked in New Zealand as a general practitioner and in Canada as a medical officer of health. At the time of the report he was a research fellow at Harvard University School of Public Health. Despite this wide ranging experience, he had never visited Great Britain so was unfamiliar with the ...

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Collings report on general practice in England in 1950: unrecognised, pioneering piece of British social research?

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Collings's grim description of postwar general practice in England and his sombre analysis of its prospects created an immediate sensation. In addition to its value as a historical document, the report is also regarded as a turning point in the postwar history of British general practice.

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WISE GP

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WiseGP - Championing the clinical scholarship supporting the Knowledge Work of person-centred General Practice.

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Pallaborative

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Find us at www.pallaborative.org.uk

About Us

We are a collaboration of health care professionals working in specialist palliative care, patients and members of the public from across the North West of England , originally formed back in 1995. We are committed to improving the quality of care for people with advanced progressive disease and to ensure care is based on the best and most up to date evidence possible. A key strength is multi-professional involvement and the motivation and commitment of our members.

Guidelines You Can Trust

Our Standards and Guidelines for palliative and end of life care are now developed using a robust process which has been accredited by NICE. They are a great source of information with advice for a range of different symptoms and situations and can be used by all healthcare professionals.

Training Opportunities for all of your Team

Our Education and Training programme helps people improve their confidence and skills in clinical audit, searching the literature, reviewing evidence and a range of quality improvement activities. Our bimonthly regional meetings are a great way to stay up to date with the latest information and join discussions about developing standards for care delivery.

Regional Clinical Audit with Local Impact

Our comprehensive annual clinical Audit Programme, is led by experienced clinicians and focuses on areas that are most important to patients and professionals. There is also localised reporting specific to your team, organisation or locality benchmarked against regional results. A great way to drive improvements in care.

Links to Research

We want to contribute to grow the evidence base for palliative care and are using our work to develop research questions and proposals.

Embracing the Digital Age

Our new website (www.pallaborative.org.uk) has been built with a mobile first appearance, meaning that our material, including all of the clinical guidelines, are easily readable on smartphones, tablets and desk top computers alike. Development of an App is next on the horizon.

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Don't miss the Pallaborative NorthWest Education Special- l a MS Teams Live event tomorrow- Thursday 15th July at 1pm Two fabulous speakers- two fascinating topics and one opportunity We really hope you can join us

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I work clinically as a consultant and academically as a researcher in palliative medicine. I have found the audit and guidelines extremely beneficial from a clinical practice standpoint. Notably, the process to develop the guidelines is thorough, which provides reassurance that the resultant guidelines are appropriate, relevant and evidence-based for the patients we manage in palliative care."

As a clinical nurse specialist and project manager for the regional audit and Guideline Development Group for Continuous Subcutaneous Infusions, the process has enhanced my knowledge, intellectual abilities and methodologies to do and lead audit. It has enabled me to further enhance management and leadership skills and become more proficient at conducting literature reviews.

In practice the regional guidelines and standards are of great importance. The up-to-date evidence-based guidance supports us in the management of complex symptoms for patients who have specialist palliative care needs.

The bi-monthly meetings are great for networking with fellow professionals across the network who work in a number of different settings.

The Regional audit process has introduced many members of the wider MDT to the process of the audit cycle.It has made it very accessible and delivers fantastic, real world results, recommendations and clinical guidance
This is really useful for my clinical practice as a doctor, and to the practice of all members of the wider MDT. The opportunity to see the process from the initial idea, to the clinical question, to the literature search, to the questionnaires, to the results analysis and ultimately the presentation and standards and guideline is a unique opportunity

The whole process affords us the chance to meet people and work with them across the Network and is a great way to meet fellow health care professionals and forge links across the hospital, community and hospice settings in specialist palliative care.

I've found the whole regional audit process to be very comprehensive. For me this has included training in searching and appraising available evidence, support from a multi-professional team in undertaking audit, presenting results and developing guidelines.

This has been very beneficial for my practice, both in the delivery of evidence based care to patients and in teaching other health care professionals.

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Welcome to our web pages for Pallaborative North West. We host an exciting programme of clinical audit, guideline development and education, useful for all health care professionals who care for people with advanced, progressive disease. Our clinical standards and guidelines for palliative and end of life care are developed using a robust process and are NICE...

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This website is designed for use by General Practitioners and other healthcare professionals. The content is not exhaustive and assumes a standard level of GP professional knowledge. The information here is intended to support clinical judgement and shared decision making alongside clinical guidelines and standard practice.

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C&M Library and knowledge service

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Search DISCOVERY, using the search box below, and find books, e-books, full text journal articles and more, all in one place.

You can use the search freely but to access the fulltext of some resources you will need an NHS OpenAthens account. If you haven't already got one, please click here to register.

For a more in-depth search, please click here to use the Healthcare Databases.

Let the Library Team help you access resources, find evidence-based information and keep you up to date.

You can access all of our services and resources via:

The library at Nightingale House, Whiston Hospital

The outreach librarian visiting you at your place of work

This website

Our enquiry service

WHAT'S NEW

We're Back!

The physical library is once more open for business . We are working with reduced library staff, so please be patient with us.
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LKS Outreach Newsletter - Issue 7

Issue 7 of our newsletter for all our Community, CCG and General Practice staff is now available on our Outreach page.
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CLINICAL DECISION SUPPORT TOOLS

UpToDate is an evidence-based physician-authored clinical decision support resource which assists in making the right point-of-care decisions. NB: Only available to St Helens and Knowsley Teaching Hospitals NHS Trust employees.

BMJ Best Practice is a clinical decision support tool, uniquely structured around the patient consultation, with advice on symptom evaluation, test to order and treatment approach. This resource is available to ALL NHS employees using their NHS OpenAthens login.

MY JOURNALS

NHS staff and students can access over 5000 full-text electronic journals via My Journals.

Please remember to login with your NHS OpenAthens account. If you haven't got one yet, please click here to register.

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You can use the search freely but to access the fulltext of some resources you will need an NHS OpenAthens account. If you haven't already got one, please click here to register. For a more in-depth search, please click here to use the Healthcare Databases.

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Pan Mersey guidance

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Web based formulary

Smartphone formulary app

Definitions and Criteria for Categorisation of Medicines

Further information regarding the process for review and categorisation, including devices, can be found in the Policy for the Pan Mersey Area Prescribing Committee.

Categorisation of Medicines

Key to recommendations

Red Drugs which should be prescribed only by a specialist clinician.

Amber medicines are considered suitable for primary care prescribing following varied levels of specialist input.

AMBER Recommended requires specialist assessment and recommendation to GP to prescribe in Primary Care.

AMBER Initiated requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose and the patient's condition is achieved and the patient has been reviewed by the specialist.

AMBER Patient Retained requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose and the patient's condition is achieved and the patient had been reviewed by the specialist. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required.

PURPLE Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement.

GREY These medicines are still being evaluated according to local processes and a decision on whether to commission their use has not yet been made. They should not be prescribed in any setting.

BLACK Medicines not recommended for use because of lack of evidence of clinical effectiveness, cost prioritisation or concerns over safety.

GREEN Medicines for which primary care prescribers would normally take full responsibility for prescribing and monitoring. Green status does not imply that a medicine is superior to existing first-line drugs or is a recommended formulary choice.

Managing common infections in adults

Cost comparison charts

Cost comparison charts

The Regional Drugs and Therapeutics Centre (RDTC) is a non commercial, not for profit NHS organisation hosted by the Newcastle Upon Tyne Hospitals NHS Trust.

Established in 1991 the multi-disciplinary team, comprising of pharmacists, physicians, scientists and support staff aim to promote the safe, effective and economical use of medicines within the NHS across the North of England through the provision of high quality information and expert advice.

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Web based formulary Smartphone formulary app Definitions and Criteria for Categorisation of Medicines Further information regarding the process for review and categorisation, including devices, can be found in the Policy for the Pan Mersey Area Prescribing Committee. Categorisation of Medicines Key to recommendations Red Drugs which should be prescribed only by a specialist clinician.

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Contact cares

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Contact Cares (former IASH) forms an important part of this approach, as it aims to improve access to a wide range of services and to provide advice and support from a wide range of professionals, who are located in one place.

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NICE CKS

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The NICE Clinical Knowledge Summaries (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories.

CKS content is produced by Clarity Informatics Limited. It is available to users outside the UK via subscription from the Prodigy website.

If you believe you are seeing this page in error please contact us.

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The NICE Clinical Knowledge Summaries (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories. CKS content is produced by Clarity Informatics Limited. It is available to users outside the UK via subscription from the Prodigy website. If you believe you are seeing this page in error please contact us.

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RCGP Self test

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Skip Intended for UK Health Care Professionals Only

Welcome to GP SelfTest the RCGP's learning needs assessment tool for GPs at all career stages, from those preparing for the MRCGP AKT to those preparing for their annual appraisals.
FREE unlimited access for all RCGP Members and AiTs
Non-members click here to subscribe

Over 2000 questions

All questions written by practising GPs

Detailed clinical scenarios

Question feedback and links to further resources

Certificates for CPD portfolio

Peer comparison scores

Eight different types of test including:

Curriculum wide learning assessments

MRCGP AKT style revision tests

Topic specific assessments

Short lucky dip quizzes

TEST - Thousands of quality assured questions will support your MRCGP exam revision and learning-assessment. Practise with AKT style questions and mock exams.

REVIEW - Fit your AKT preparation and medical revision around your busy schedule with short quizzes and topic specific tests. Analyse your performance and access further resources.

ACHIEVE - An extensive question bank complemented by up-to-date resources that enable GPs to identify areas for improvement and build their all-round knowledge for CPD and appraisals.

Dr Kofo Jegede, a GP in North East London, explains how she sees GPST benefiting her everyday practice and CPD needs.

Have a query?

Please visit our frequently asked questions page.

For help with logging in please see our user guide.

For all content or technical queries, please email gpselftest@rcgp.org.uk.

If you have a question regarding GP Self-Assessments International Induction or Return to Practice Programmes please email IGPR@rcgp.org.uk.

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Skip Intended for UK Health Care Professionals Only Welcome to GP SelfTest the RCGP's learning needs assessment tool for GPs at all career stages, from those preparing for the MRCGP AKT to those preparing for their annual appraisals.

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RCGP Clinical Toolkits

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These clinical toolkits have been developed in partnership between the RCGP and our funding and delivery partners. The resources have been created for primary healthcare professionals, patients and carers. These toolkits can be used to assist in the delivery of safe and effective care to patients.

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Bradford VTS

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Site created by Dr Ramesh Mehay (Bradford, UK), rameshmehay@googlemail.com

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Emedica 30 day AKT challenge

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Excellence in medical education - experts in GP Specialty Training, MRCGP AKT, CSA and GP Careers

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Twitter GP journal club

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Welcome to GP Journal Club

GP Journal Club (#gpjc) uses Twitter to discuss primary care relevant research, guidelines, and editorials.

Each month we have a different co-chair, who chooses an article. We then set the date and time for a tweet chat.

Anyone from around the world with an interest in primary care can take part.

Our aim is to harness the power of social media to:

facilitate discussion of topical issues

encourage international collaboration, and

promote evidence-based practice.

All contributors are welcome!

The club is hosted by the Centre for Academic Primary Care at the University of Bristol and supported by the British Journal of General Practice (BJGP).

If you're interested in how we got started, see this article in BJGP Life.

Recent and forthcoming tweet chats
Click on the titles for links to articles to be discussed, transcripts of the chats (after they've happened) and other relevant links. 2021 Break due to the coronavirus pandemic 2019
Sunday 22 September 2019, 20:00-21:00 (BST)
Management of depression and referral of older people to psychological therapies - Co-chair: Dr Nadia Llanwarne (@nadiallanwarne)

Sunday 3 March 2019 19:30-20:30 (GMT)
Low carbohydrate diets and their impact on consultation techniques for people with type 2 diabetes: Co-chair Dr Ishani Patel (@drishanipatel)

How to take part

Want to know more about how to take part? See How to participate (PDF, 111kB) for hints and tips.

Fancy co-chairing?

Being a co-chair is a great way to share your knowledge on a topic, gain CPD, brush up on your critical appraisal skills and is great fun! Anyone can volunteer, regardless of your background. We are always on hand to help during the chat. If you want to know more about what's involved, then see How to be a co-chair (PDF, 202kB). If you would like to volunteer or find out more about what's involved, contact lucy.pocock@bristol.ac.uk

Contact

Dr Lucy Pocock, Primary Care Research GP Career Progression Fellow, Centre for Academic Primary Care, University of Bristol

Email: lucy.pocock@bristol.ac.uk

Twitter: @GPjournalclub

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GP Journal Club (#gpjc) uses Twitter to discuss primary care relevant research, guidelines, and editorials. Each month we have a different co-chair, who chooses an article. We then set the date and time for a tweet chat. Anyone from around the world with an interest in primary care can take part.

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Syncing of your Blue Stream Academy eLearning to your FourteenFish Account

15% discount on our Appraisal Toolkit for Blue Stream Academy customers

25% discount on your practice's Blue Stream Academy subscription

We are really excited to announce our partnership with Blue Stream Academy, with the accompanying integration to the FourteenFish Appraisal Toolkit and Trainee Portfolio. If all GPs in your practice use FourteenFish for their appraisal, your practice can save 25% off the Blue Stream Academy eLearning Suite and 15% off the FourteenFish Appraisal Toolkit.

Find out more...

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Appraisal Toolkit, AKT, RCA, Education, Trainee Portfolio - FourteenFish

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Syncing of your Blue Stream Academy eLearning to your FourteenFish Account 15% discount on our Appraisal Toolkit for Blue Stream Academy customers 25% discount on your practice's Blue Stream Academy subscription We are really excited to announce our partnership with Blue Stream Academy, with the accompanying integration to the FourteenFish Appraisal Toolkit and Trainee Portfolio.

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InnovAiT

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Official journal of the Royal College of General Practitioners (RCGP). Promotes excellence in primary care through quality education. Designed to support Associates-in-Training (AiTs), InnovAiT also provides valuable information for GP trainers, newly qualified GPs, practice nurses, foundation level doctors and medical students. A member of the Committee on Publication Ethics (COPE).

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Flash AKT

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eGPlearning

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eGPlearning is a site designed to help with technology-enhanced primary care and learning.

Services

Hussain 'DrGandalf' Gandhi provides a range of services to improve digital primary care. This includes health tech consultancy, social media training for clinicians, video consultation skills training and med tech reviews.

If you are interested in these see contact either on twitter or via email.

Subscribe and listen to the UK's leading primary care focused health tech podcast by two GPs - Andy and Gandhi. We cover a variety of areas like deep dives into the health tech that impacts primary care like video consultations, artificial intelligence and wearables to name a few. In addition, we interview notable health teach entrepreneurs who provide resources for primary care to work smarter, faster and help you to be more effective.

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eGPlearning is a site designed to help with technology-enhanced primary care and learning. Hussain 'DrGandalf' Gandhi provides a range of services to improve digital primary care. This includes health tech consultancy, social media training for clinicians, video consultation skills training and med tech reviews.

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Prescribing error cases examples

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Objective To estimate the incidence of avoidable significant harm in primary care in England; describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents.

Design Retrospective case note review. Patients with significant health problems were identified and clinical judgements were made on avoidability and severity of harm. Factors contributing to avoidable harm were identified and recorded.

Participants Thirteen general practitioners (GPs) undertook a retrospective case note review of a sample of 14 407 primary care patients registered with 12 randomly selected general practices from three regions in England (total list size: 92 255 patients).

Main outcome measures The incidence of significant harm considered at least 'probably avoidable' and the nature of the safety incidents.

Results The rate of significant harm considered at least probably avoidable was 35.6 (95% CI 23.3 to 48.0) per 100 000 patient-years (57.9, 95% CI 42.2 to 73.7, per 100 000 based on a sensitivity analysis). Overall, 74 cases of avoidable harm were detected, involving 72 patients. Three types of incident accounted for more than 90% of the problems: problems with diagnosis accounted for 45/74 (60.8%) primary incidents, followed by medication-related problems (n=19, 25.7%) and delayed referrals (n=8, 10.8%). In 59 (79.7%) cases, the significant harm could have been identified sooner (n=48) or prevented (n=11) if the GP had taken actions aligned with evidence-based guidelines.

Conclusion There is likely to be a substantial burden of avoidable significant harm attributable to primary care in England with diagnostic error accounting for most harms. Based on the contributory factors we found, improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care.

Participants

We used a stratified random sampling approach to invite general practices to participate from three different areas of England. We undertook a retrospective case note review of an open cohort of all primary care patients registered with participating general practices (between 1 April 2015 and 31 March 2016) to identify cases of avoidable significant harm.

Recruitment and training of data collectors

GPs with at least 5 years' experience in general practice were recruited to collect data from the participating practices and were provided with training. 16

Sampling of patient records

We sampled patient records in three stages. In stage 1, we identified the total patient population of the practices at the start of the retrospective cohort (1 April 2015). In stage 2, we used electronic registry queries to identify patients at increased risk of significant health problems and/or avoidable significant harm (the 'enhanced sample'). Drawing on suggestions made by the research commissioners, the literature on avoidable harm in primary care 8 and our own experience of analysing reports of harm associated with primary care, 15 we included patients who had died 17 been admitted to secondary care, 18 were resident in a care home, 19 had multimorbidity 15 or polypharmacy, 20 21 had undergone an invasive procedure in general practice 22 or had been certified unfit for work long term. In stage 3, one of the GP data collectors screened the electronic health record of each patient in the enhanced sample to identify any new significant health problems experienced by patients over the 12 months of the study (1 April 2015-31 March 2016). The GPs then undertook detailed retrospective reviews of the records of this final sample of patients to identify the extent to which errors in primary healthcare provision contributed to these problems.

For the purposes of sensitivity analysis (recognising that cases might have been missed by our sampling approach), the GP data collectors also undertook a detailed records review for the following:

2.5% random sample of the stage 1 population, not including patients identified for the stage 2 enhanced sample; each record was examined by a single GP reviewer.

10% random sample of the stage 2 enhanced sample; each record was examined by a second GP reviewer.

Identification of avoidable significant harm and factors associated with this

For those patients with significant health problems, the GP data collectors recorded whether they found any evidence of avoidable harm. If so, the GPs provided a detailed written account of the principal problem in the patient's primary care that led to the significant health problem, a narrative describing the manner in which the significant health problem could have potentially been prevented within primary care, and a judgement on the avoidability of the significant health problem using a validated 6-point scale (see table 1). 17 23 All cases were considered in detail by the study team, and the GP data collectors were asked to provide additional information if any clarification were needed. To ensure consistency, the study team made the final judgement, through consensus, in terms of the classification of avoidable significant harm.

Data collection and coding

Each of the participating general practices was visited by an informatician from the study team who collected baseline data on the practice population and ran a computer search to identify patients for the enhanced sample and for the sensitivity analyses. Using encrypted tablet computers and a virtual private network connection, the GP data collectors entered anonymised data directly into a database on a secure server at Cardiff University. The nature of the avoidable harm was recorded by the GP data collectors using the comprehensive patient safety classification system developed in the Primary Care Patient Safety Classification study. 24

Analysis

We estimated the incidence of significant harm that was considered at least probably avoidable (our primary outcome-avoidability score of 4 or more) and at least possibly avoidable (avoidability score 3 or more) accompanied by 95% CIs. 16 We assessed inter-rater reliability of judgements made using the Cohen's kappa statistic (with 95% CI).

Members of the study team then undertook a detailed analysis of the information provided on each case of potentially avoidable significant harm and included cases with at least 'slight to modest' (score or more) evidence of avoidability, as we judged that even in these cases there were important insights. We analysed the data recorded on the cases and examined the relationships between different types of incident and the factors that contributed to these incidents. As a result, we identified the most important factors contributing to avoidable significant harm.

Sensitivity analysis

The examination of the 2.5% sample of the patient population did not identify any additional cases of significant harm considered at least possibly avoidable. The examination of the 10% sample of the enhanced sample by a second GP reviewer identified two further cases of significant harm considered to be at least probably avoidable and four cases considered at least possibly avoidable, based on the final judgement of the study team. This means that had all the patient records in the enhanced sample been assessed independently by two GPs, there could have been an additional 20 cases considered at least probably avoidable, and 40 cases of significant harm considered at least possibly avoidable. In the sensitivity analysis, this translated into rates of 57.9 (95% CI 42.2 to 73.7) per 100 000 patient-years for significant harm considered at least probably avoidable, and 101.4 (95% CI 80.5 to 122.2) per 100 000 patient-years for significant harm considered at least possibly avoidable.

Inter-rater reliability

Where an assessment of avoidability was done, there was 77.0% agreement between GP data collectors and the study team about whether the case was considered at least possibly avoidable (Cohen's kappa: 0.49, 95% CI 0.29 to 0.69). For the 10% sample of the enhanced sample, there was 71.5% agreement between the first and second GP reviewers that a patient had at least one significant health problem (kappa: 0.33, 95% CI 0.27 to 0.38), and where an avoidability assessment was done independently by two GP data collectors, there was a 67.6% agreement about whether the significant harm was considered at least possibly avoidable (kappa: 0.34, 95% CI: 0.02 to 0.66).

Analysis of the nature and causes of avoidable significant harm

For the detailed analysis of the nature and causes of avoidable significant harm, we included 74 cases involving 72 patients. The distribution of avoidability scores for these cases is shown in table 4.

The distribution of different types of primary incidents for the 74 cases is shown in table 5, with problems with diagnosis accounting for 60.8%; medication-related problems for 25.7% and delayed referrals for 10.8% (the latter relating to situations where a clinician had decided that a referral was needed, but there was such a delay in the referral being made that the patient may have been harmed as a result). Examples of these incidents are shown in boxes 2 and 3. In relation to the 74 primary incidents, 114 underlying 'contributory factors' were identified, and these are shown in table 6. Patient factors accounted for 71.9%, with comorbidities or multimorbidities being the most important categories (24.6% of all contributory factors), while 17.5% of factors included issues such as not taking medicines as prescribed, problems with eliciting relevant information from patients or caregivers, not following medical advice and presenting with multiple issues in a single consultation. Factors such as multimorbidity and frailty contributed either through offering alternative explanations for symptoms or by presenting clinicians with multiple competing demands. Organisational factors accounted for 21.1% of contributory factors, while staff factors such as inadequate knowledge, skills or mistakes by healthcare professionals accounted for 7.0%. In 59 (79.7%) of the 74 cases, the significant harm could have been identified sooner (48 cases) or prevented (11 cases) if the GP had taken actions aligned with evidence-based guidelines (see examples in box 2).

These 74 cases involved 115 healthcare professionals (81 (70.4%) GPs and 10 (8.7%) practice nurses), and only 4 of these (3.5%) were clearly identifiable as being from outside the participating general practices (community nurse, community optometrist, community physiotherapist and community psychiatric nurse).

Principal findings

The estimated incidence of significant harm in English primary care considered at least 'probably' avoidable is between 35.6 and 57.9 per 100 000 patient-years (the latter figure being based on sensitivity analysis). Extrapolating our findings to the English population of 55.6 million (mid-year 2017), we found that there are likely to be between 19 800 and 32 200 cases of 'probably avoidable' significant harm to patients each year.

The three major sources of significant avoidable harm in general practice were diagnostic error (60.8% of the avoidable incidents), medication incidents (25.7%) and delayed referrals (10.8%). In 79.7% of cases, the significant harm could have been identified sooner or prevented if the GP had taken actions aligned with evidence-based guidelines. The study identified a mix of organisational, clinician and patient contributory factors associated with the avoidable incidents. The majority of these were patient factors (71.9% of the total contributory factors identified), including multimorbidity, old age and complexity arising from pathophysiological factors such as frailty. Most of these factors are not ameliorable but highlight the challenges that healthcare professionals face when trying to avoid patients coming to harm. Of the organisational factors, problems relating to continuity and coordination of care (between providers and within primary care) were most important (14.1% of the total). For example, the patient did not experience a 'seamless service' due to failures in coordination and sharing of information between different providers across the health and social care system, disconnect between multiple members of the primary care in the same practice and lack of care coordination as a patient transitions from secondary back to primary care. Mitigating risk for future patients could be achieved through targeting the organisational structures and processes underpinning the most frequent contributing factors.

Strengths and limitations of the study

This is one of the most comprehensive studies of avoidable harm in primary care, 8 10 and one of only two records review studies we are aware of that is large enough to report on substantial numbers of significant harms. 13 It is the only study of which we are aware that has reported the incidence of avoidable harm based on independent review of primary care clinical records. In terms of other potential methods of investigation, independent retrospective case note review has significant advantages over incident reports, which are more at risk of selection bias and are not well suited to accurately estimating the incidence of avoidable harm. It also has advantages over database studies because detailed examination is required of the healthcare records (including hospital correspondence), which is not possible through clinical databases. One major limitation of case note review is the onerous task of searching for and identifying important information to build a narrative, based on what is explicitly stated or from what is absent based on the clinician's knowledge of the relevant evidence-based guidelines.

We used a stratified random sampling approach to recruit 12 general practices from three geographically different regions of England, and the independent GPs involved in data collection were experienced and were given thorough training. We used a validated method for judging the avoidability of harm 14 and a comprehensive validated system for classifying the underlying causes of patient harm. 15 Our methodological approach used the recursive model of incident analysis and permitted us to capture the series of 'contributing incidents' that led to the final 'principal incident' prior to the patient experiencing a harmful outcome. 25 This meant we could provide the most robust and comprehensive assessment of the patient safety incidents implicated in significant avoidable harm outcomes, as well as consider the apparent underlying events when formulating our recommendations to mitigate future risk to patients.

Only a quarter of the general practices in the stratified random sample agreed to participate, and this is a limitation from an epidemiological perspective. The most common reason cited for not participating was lack of time. Although the characteristics of the practices recruited were similar to those in England in most respects, none of the study practices received an overall CQC rating of 'inadequate' or 'requires improvement', whereas 2.6% and 9.1% (respectively) of all English practices received these ratings. If CQC ratings are associated with patient safety, then our study may underestimate the overall incidence of avoidable significant harm in English general practices. Our inter-rater reliability assessments showed that there was moderate agreement between the GPs in their identification of patients with significant health problems, and their judgements as to whether a patient had experienced avoidable significant harm. Even with our sensitivity analysis, the upper limit of our estimates of the incidence of avoidable significant harm may be an underestimate. This highlights the uncertainties of estimates of frequency of harm originating from case note reviews that rely on clinical judgement. It suggests that our study could have missed some cases of avoidable significant harm but could also have included cases that others might not consider to be 'significant' or 'avoidable'.

Through our enhanced sample, we successfully identified patients most likely to have avoidable significant harm, but the criteria we used might be difficult to replicate in other countries. We did, however, manage to identify these patients through electronic medical records, and so a similar approach should be possible in countries with comprehensive primary care electronic records. Our study was not designed to detect near misses.

Comparison with other studies

We recognise from our previous systematic reviews 8 10 that comparing studies of avoidable harm is difficult because of different study designs and different ways of applying definitions of avoidable harm. One key difference between our study and almost all previous studies is that we report the incidence of avoidable harm rather than the prevalence (per consultation). Our approach allows for a clearer estimate of the public health burden of avoidable harm while also recognising that some harms, especially in a primary care setting, may occur over several consultations (eg, delayed diagnosis). Also, we have focused specifically on significant harm (such as a clinically important delay in cancer diagnosis) to ensure that our findings reflect a health burden that is unquestionably of importance to patients, the public, clinicians and policy makers.

The only study we are aware of that was of a similar large size to ours, while also reporting on severity, was from a convenience sample of 48 health centres in Spain with health professionals reporting any incidents causing harm. 13 From 96 047 consultations, 773 harms were detected with 46 of these considered 'severe'. Of all the harms, 64.3% were considered preventable, and applying this percentage to the severe harms suggests a prevalence of 30.8 severe harms per 100 000 consultations. It is not possible to directly compare this with the incidence figures from our study (where the same harm may have been apparent across several consultations over the course of the 12 months), but the overall rates of significant harm are probably not widely dissimilar.

There is considerable variation in studies reporting categories of avoidable harm as well as contributory factors. Nevertheless, our findings are in keeping with a systematic review that found that diagnostic errors were among the most important causes of avoidable harm, 10 and a review of the global burden of diagnostic errors in primary care, 26 while the systematic review 10 (and other studies) has highlighted the importance of prescribing errors. 13 In relation to diagnostic delay in cancer, a recent study has highlighted that in almost half of the cases, this is attributable to primary care, 27 with problems with clinical appraisal of the patient and referral being particularly important. Our study has specifically highlighted the importance of delays in making a referral, 15 23 and this has been highlighted as an important problem by the Institute for Healthcare Improvement. 28 In comparison with other studies, ours is unusual in reporting such a high level of patient factors contributing to patient harm. While many of these cannot be considered the reason for the harm being avoidable, the findings suggest that factors such as multimorbidity, frailty and complex presentations may make it more difficult for clinicians to make timely and accurate diagnosis and avoid medication errors. In relation to contributory factors that are avoidable, our findings are in keeping with other studies that have highlighted organisational issues and communication problems. 8 12 29

Implications for clinicians and policy makers

This study has estimated the incidence of significant harm in English primary care considered at least probably avoidable, which translates to three to four cases per year for an average general practice of 8000 patients. Efforts to make improvements should focus on addressing the structures and processes underpinning the identified patient, clinician and organisational contributing factors. For example, better organisation of key systems (eg, referrals, test result management, identifying non-adherence) and related administration could have prevented most incidents. Some of the earliest patient safety studies carried out in primary care over two decades ago pointed to administrative failures, such as the mismanagement of test results, as the root cause of the the most common incidents concerning diagnosis and medication, 30-32 and an Australian study concluded about 70% of incidents were related to processes of providing healthcare, rather than gaps in the knowledge and skills of health professionals. 11 The current study provides considerable insights into the ameliorable contributory factors associated with avoidable significant harm in primary care, which in turn have generated the following suggestions for improvement.

More effective implementation of existing information technology solutions could ensure that planned action such as referrals take place in a timely way. 26 Enhanced team coordination and communication could ensure that patients are seen (or have necessary investigations) or that they are recalled for follow-up investigations or assessment when needed. Currently, it is largely down to individual primary care teams and individual healthcare practitioners to develop their own strategies. Without stifling innovation, however, it might be helpful to model 'what best practice looks like' in relation to preventing patients from coming to harm. Interventions like the 'QRISK3-2018' algorithm to calculate a person's risk of developing a 'heart attack' or stroke are now commonly integrated into electronic health record systems and used by clinicians to explain and manage risk and support patient decision-making. 33 In a similar way, the factors implicated in patient safety incidents that we have identified might be considered as signals for future algorithms for development and validation, either to flag up patients for timely clinical review to mitigate current risk levels or to proactively detect risks of future unsafe care.

Our study suggests that lack of continuity of care may contribute to avoidable significant harm in some cases. 34 Recent systematic reviews suggest that low continuity of care is associated with a higher risk of mortality across different healthcare settings 35 and specifically in general practice. 36 In some cases in our study, follow-up by the same primary healthcare practitioner could have been helpful to enable earlier recognition of the progression of a serious health problem. In other cases, better 'informational continuity' 37 could have helped to ensure that the assessment and suggested follow-up plans from a previous consultation better informed the next consultation. This should be facilitated by electronic health records, but we found several examples where recommendations from one consultation were not acted on in a subsequent consultation involving a different healthcare practitioner. Nevertheless, high levels of personal continuity may not always be best for patients. A recent qualitative study showed a mixed picture in terms of patients' perceptions of whether personal continuity improved safety, or not, 38 while a cross-sectional ecological study found that general practices that appeared to have high levels of personal continuity did fewer urgent referrals 39; this does not necessary mean they were less safe, but it is a potential cause for concern.

Some of the cases of avoidable significant harm in our study were associated with GPs having too many problems to deal with adequately in a single consultation, with significant health problems not detected early enough because of lack of effective and timely clinical history taking, examination or investigation. Some of the contributory factors associated with patient behaviours may have resulted from their concerns being unrecognised or unresolved, as highlighted in a study of missed opportunities in cancer diagnosis. 40 When such incidents occur in general practice, it is essential that practice teams know how to generate learning from the incident, including how to identify vulnerabilities in their existing structures and processes, and feel confident to plan and test changes that could achieve improved outcomes for future patients. 41 The introduction of quality improvement domains into 2019/2020 Quality and Outcomes Framework by NHS England represents a promising commitment for supporting practices to learn about and develop their approach to systems improvement 42 as does the 2019 NHS Patient Safety Strategy. 43

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Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review

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Objective To estimate the incidence of avoidable significant harm in primary care in England; describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents. Design Retrospective case note review. Patients with significant health problems were identified and clinical judgements were made on avoidability and severity of harm.

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BUKU

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OUR AIM

To provide answers and education about the commonest questions posed to medical specialty doctors in order to free up time for clinicians, improve workload and improve patient care

The App was conceived by a UK haematology registrar and consultant in 2017 as Buku Haematology, and has now been downloaded over 20,000 times internationally and has the support of the North-East region haematology consultant body. It is installed on clinician smartphone devices in two trusts in the North-East and has ORCHA approval (the organisation who provide accreditation for Apps used in the NHS).

The App has now expanded to include renal and endocrine specialties, who share similar types of clinical query and we have plans to add further specialties in the coming months.

"

Your app is one of my favourites, I really think it is so excellent. I like how you have structured the topics, the chosen labels, and amount of info in each section. So thank you very much to everyone involved in the creation and maintenance. I really appreciate that this app is free, easy to use, and how it has consequently improved my practice and patient care.

It's brilliant, I use it a lot and helps guide my investigation and know when to refer/worry etc. Thank you!

Dear Buku Haematology. Thank you very much for your app, I have found it very useful whilst working as a Band 5 Biomedical Scientist. Keep up the good work! All the best.

I am a consultant haematologist in the South of England. this app is fantastic and I will be promoting it's use locally.

This is a brilliant app.

Excellent resource - accessible with lots or relevant information, gets to the point.

"

We are incredibly grateful to have the endorsement of the British Society for Haematology regarding our aims of improving patient care and reducing the referral burden on haematologists with our Buku Haematology content.

(The BSH but does not endorse specific content nor provide any input or guidance regarding content within Buku Medicine.)

Dr Alex langridge

Alex is a Haematology Registrar in the North-East of England and created Buku Haematology in 2017. He writes content alongside Steve O'Brien, and performs the day-to-day maintenance and promotion of Buku Medicine. His interests include clinical informatics alongside his clinical haematology, is an NHS Clinical Entrepreneur and is on the British Society for Haematology Education Committee.

Professor Stephen o'Brien

Steve is a Consultant Haematologist at Newcastle Hospitals NHS Foundation Trust, a Professor of Haematology at Newcastle University and co-founder of Buku Haematology. He is an international CML expert and also the chair of NICE Technology Appraisal Committee C. He has an interest in technology and the potential of artificial intelligence in medicine.

Dr Kerri Devine

Kerri is a Diabetes & Endocrinology registrar originating from Glasgow but now training in the North East of England. She is interested in steroid physiology, improving the patient experience and making endocrinology more accessible. Kerri undertakes day-to-day maintenance and promotion of Buku Medicine.

Acknowledgements

We would like to specifically thank those that have helped us move Buku Medicine forward

Thanks to Northumbria Healthcare NHS Foundation Trust for providing Alex with protected time to work on the App while working as a clinical informatics fellow.

Thanks to the Academic Health Sciences Network North-East and North Cumbria for their support for our innovation.

Thanks to Health Education England North East for their support of the App-they have helped us to get things off the ground and continue to support our work. ﻿

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The App was conceived by a UK haematology registrar and consultant in 2017 as Buku Haematology, and has now been downloaded over 20,000 times internationally and has the support of the North-East region haematology consultant body. It is installed on clinician smartphone devices in two trusts in the North-East and has ORCHA approval (the organisation who provide accreditation for Apps used in the NHS).

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BJGP

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The second BJGP Webinar took place on 26 May, focusing on Cancer and primary care. The webinar was introduced by Prof. Fiona Walter, from Queen Mary University of London & University of Cambridge. There were presentations, a panel discussion, and time for attendees' questions. Jump to a 2-minute summary of the clinical messages from each speaker. For more jump links, watch on YouTube and 'show more' to navigate to sections of interest. Keep up-to-date, follow #BJGPWebinar on Twitter, and BJGP Webinar on BJGP Life.

New research from University College London shows that remote healthcare consultations with patients with dementia are easier for issues like medicines, but new issues and physical signs are more difficult when remote. Remote consultations that were described as feasible were mostly by telephone and managed by the carer. Practitioners engaging with people living with dementia and their carers should make extra effort to ensure the efficacy of remote healthcare consultations, addressing difficulties by encouraging use of prompts to remember problems, assessing new emerging issues, rescheduling/missed calls, and inclusion of the person with dementia's voice. Listen to the podcast interview with Remco Tuijt.

Dr Alison May Berner discusses new research on cervical screening for trans men and non-binary people. She explains that trans men and non-binary people assigned female at birth (TMNB) experience barriers to accessing adequate cervical screening at personal, interpersonal, and institutional levels, and are less likely to engage in screening than cisgender women. Findings show that many trans men and non-binary people don't have hysterectomies, 10% clearly do not want a hysterectomy, and 35% are not sure. Unfortunately, current NHS recording of sex/gender as only male or female misses trans men from the screening register. Cervical screening uptake could be increased with improved training for providers, more inclusive clinical environments, and by embracing new testing methods such as self-taken swabs. More information is available from Jo's Cervical Cancer Trust.

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The second BJGP Webinar took place on 26 May, focusing on Cancer and primary care. The webinar was introduced by Prof. Fiona Walter, from Queen Mary University of London & University of Cambridge. There were presentations, a panel discussion, and time for attendees' questions. Jump to a 2-minute summary of the clinical messages from each speaker.

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Preventable death tracker

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Under The Coroners Rule 1984, coroners in England and Wales have a duty to report and communicate a death when the coroner believes that action should be taken to prevent similar deaths. In 2013, these reports, named Prevent Future Deaths or PFDs, became mandated under Paragraph 7 of Schedule 5 of The Coroners and Justice Act 2009, and regulations 28 and 29 of The Coroners (Investigations) Regulations 2013. Under these regulations, parties that receive a PFD report are required to respond to the coroner within 56 days of receiving the report, to outline actions taken or proposed that address the coroner's concerns.

Many recognise the important lessons outlined by coroners in PFDs, but concerns have been raised regarding the lack of wider communication of these lessons, and insufficient monitoring of the statutory requirement of responding to PFDs and taking action. We have created this website - the Preventable Deaths Tracker - and the Preventable Deaths Database to collate and display the data from PFDs in a visual, filterable, and searchable format that others can use. We have also launched the Coroners' Concerns to Prevent Harms series in BMJ Evidence Based Medicine to disseminate important lessons that serve patient safety and prevent similar deaths.

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A platform to explore concerns raised by coroners to prevent future deaths - Preventable Deaths Tracker

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Under The Coroners Rule 1984, coroners in England and Wales have a duty to report and communicate a death when the coroner believes that action should be taken to prevent similar deaths. In 2013, these reports, named Prevent Future Deaths or PFDs, became mandated under Paragraph 7 of Schedule 5 of The Coroners and Justice Act 2009, [...]

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For Authors

Family Practice is an international journal aimed at practitioners, teachers, and researchers in the fields of family medicine, general practice, and primary care in both developed and developing countries. Find out more about submitting from the below links.

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For Authors Family Practice is an international journal aimed at practitioners, teachers, and researchers in the fields of family medicine, general practice, and primary care in both developed and developing countries. Find out more about submitting from the below links.

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SQUIRE template for QI reporting

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The Inverse Care Law

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Epidemiology of multi-morbidity

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Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study

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Our findings challenge the single-disease framework by which most health care, medical research, and medical education is configured. A complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas.

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Wizard and Gatekeeper

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1. Research

2. The Gatekeeper and the...

3. The Gatekeeper and the Wizard: a fairy tale.

Research Article British Medical Journal 1989; 298 doi: Cite this as: British Medical Journal 1989;298:172 https://doi.org/10.1136/bmj.298.6667.172

This is a PDF-only article. The first page of the PDF of this article appears above.

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The Gatekeeper and the Wizard: a fairy tale.

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Research The Gatekeeper and the... The Gatekeeper and the Wizard: a fairy tale. Research Article British Medical Journal 1989; 298 doi: Cite this as: British Medical Journal 1989;298:172 https://doi.org/10.1136/bmj.298.6667.172 This is a PDF-only article. The first page of the PDF of this article appears above.

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Objective Continuity of care is a long-standing feature of healthcare, especially of general practice. It is associated with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. This review aims to examine whether there is a relationship between the receipt of continuity of doctor care and mortality.

Design Systematic review without meta-analysis.

Data sources MEDLINE, Embase and the Web of Science, from 1996 to 2017.

Eligibility criteria for selecting studies Peer-reviewed primary research articles, published in English which reported measured continuity of care received by patients from any kind of doctor, in any setting, in any country, related to measured mortality of those patients.

Results Of the 726 articles identified in searches, 22 fulfilled the eligibility criteria. The studies were all cohort or cross-sectional and most adjusted for multiple potential confounding factors. These studies came from nine countries with very different cultures and health systems. We found such heterogeneity of continuity and mortality measurement methods and time frames that it was not possible to combine the results of studies. However, 18 (81.8%) high-quality studies reported statistically significant reductions in mortality, with increased continuity of care. 16 of these were with all-cause mortality. Three others showed no association and one demonstrated mixed results. These significant protective effects occurred with both generalist and specialist doctors.

Conclusions This first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates. Although all the evidence is observational, patients across cultural boundaries appear to benefit from continuity of care with both generalist and specialist doctors. Many of these articles called for continuity to be given a higher priority in healthcare planning. Despite substantial, successive, technical advances in medicine, interpersonal factors remain important.

PROSPERO registration number CRD42016042091.

Research question

Are higher levels of continuity of doctor care, in any setting, with any patient group, associated with changed mortality?

Search strategy and selection criteria

For inclusion in this systematic review (without meta-analysis), articles must have been published in the peer-reviewed literature, in the last 21 years, in English. We searched the databases of MEDLINE, Embase and the Web of Science from 1996 to 2017 by searching for 'continuity' OR 'continuity of care' together with terms for a medical doctor/physician and terms indicating death or mortality in the title or abstract (see online supplementary information-example search strategy). In addition, references of articles selected were hand-searched for additional relevant citations.

Experimental and observational study designs were considered including controlled trials, cohort studies (prospective and retrospective) and case-control studies. Systematic reviews and meta-analyses were excluded. Study participants could include any patient group, including entire populations or groups of patients with a specific disease or other feature.

Articles must have compared measured degrees of continuity of care with doctors (of any kind) to mortality rates. Any valid measure of continuity was considered, including continuity being lost or absent and articles where the continuity measure was a single appointment or visit by a general practitioner/family physician during a hospital stay. Articles about organisational continuity and general staffing numbers were excluded.

As an outcome measure, any measure of mortality was accepted, that is, all-cause, time/age-limited or cause-specific. When complications or hospital admissions were combined with death rates, we sought a separate measure of mortality alone. If this was not available, studies were excluded.

Two pairs of reviewers checked the search results and decided independently whether papers met the eligibility criteria. Initially, the title and abstract of each citation was screened. The full texts of selected articles were then examined. Disagreements were resolved by discussion, and PHE independently had the deciding vote.

Data items

The variables and outcomes extracted included basic information: authors, date and country. We also extracted study design, study population (any particular condition, setting, age group, any other inclusion or exclusion criteria and selection method), numbers of patients, measure of continuity, length of continuity measurement and doctor type (generalist doctor including general practitioner, family physician and primary care physician or specialist). We extracted the period of time for the mortality measurement, and any overlap with or interval between mortality and continuity measurement periods. We also extracted whether mortality was all-cause or a disease-specific cause or limited to a particular group, how mortality was assessed and confounding factors tested or accounted for. We also extracted an estimation of any association found, with risk ratio or OR where possible and whether higher continuity was linked to an increased or decreased mortality risk. Data were extracted independently by two reviewers (of DJPG, EW, AT and KSL), using the data-extraction table designed for this review. Disagreements were resolved as described previously.

Risk of bias

The quality and risk of bias were assessed independently for individual studies by two reviewers using the Newcastle-Ottawa Scale. 36 We also assessed relevant areas of bias in terms of the timing of continuity and mortality measurement and confounding factors considered. For continuity of care and mortality, there is a particular potential for bias in that the worsening of health status before death may cause either decreased or increased continuity of care (reverse causality), 7 so we noted whether this had been considered and adjusted for in study design. In terms of bias across studies, we considered publication bias and reporting bias in terms of whether mortality was the primary outcome.

Data analysis

Studies were analysed for a relationship between continuity of care and mortality rates, and whether this relationship was an inverse one (ie, greater continuity of care led to lower mortality rates) or not. For each study, we sought a risk metric (ie, relative risk ratio, HR or OR) from an adjusted model of data analysis in order to minimise the risk of selection bias and confounding. Where these statistical metrics were not reported, we provided any other available comparison measure.

Patient involvement statement

DJPG is a member of the St Leonard's Practice Patient Participation Group as well as the Patron of the National Association for Patient Participation. As such, he is a patient representative as well as an author. The research question and outcomes were therefore conceived by a patient from the practice based on the priorities, experience and preferences stated by patients at successive national patient conferences.

Study selection

After removal of duplicate results, 726 peer-reviewed publications were identified. No previous systematic reviews or trials on this subject were found. Of the 726 papers identified, 43 papers were selected for full-text review ( figure 1). Articles were then excluded if continuity was not clearly measured or was the dependent variable, 37-42 if the continuity of care measure was not clearly with a doctor or doctors only 35 43-49 and if mortality was not analysed or not analysed separately at any point 50-52 (eg, if it was expressed only as a composite outcome with hospitalisation). This left 22 studies for inclusion.

Study characteristics

As shown in table 1, the majority of included reports (15, 68.2%) were of retrospective cohort studies, often using insurance data. There were four prospective cohort and three cross-sectional studies. No randomised controlled trials were found. A number of cohort studies included large numbers of patients (median 16 855). All of the reports were published since 2010. The studies were carried out in nine different countries; the majority were from North America (Canada 6, USA 5). Seven were from Europe (England 3, France 2, Croatia 1 and the Netherlands 1). There were two from Taiwan and one each from Israel and South Korea.

Nine (40.9%) of the studies investigated continuity with a general practitioner/family physician/primary care physician, 3 were with specialists only 17 19 20 and 10 included continuity with doctors of any kind. Eight studies (34.8%) selected patients during or following an index hospitalisation. 15-18 20 25 26 29. Five studies studied patients with diabetes 22 23 27 30 31 and three studies focused on older patients. 13 24 31

The continuity measures used are reported in table 1. The most common measure used was the Usual Provider of Care (UPC) index which was used in 10 studies (45.5%). 13 16 17 21 23 25 26 29-31 Six studies used more than one measure, some only for sensitivity analysis. 13 21 25 26 28 29 One study 13 was designed to compare the association of different continuity measures with outcomes, including mortality. One article 18 used the occurrence of a supportive visit by a family physician to a patient in hospital and another 14 simply took loss of contact as meaning loss of continuity. Three studies 32-34 used the results of a question or questions from the annual UK national General Practice Patient Survey.

The length of time over which continuity was measured (when not a survey response or hospital visit indicating a relationship) varied greatly between studies, from a single weekend in hospital 17 up to 17 years. 24 The median length of continuity measurement was 2 years (IQR 3.75).

Most studies (20, 90.9%) reported all-cause mortality. One study 32 investigated premature mortality; under the age of 75. Another 33 used premature coronary heart disease mortality as the primary outcome. The length of time for recording deaths also showed a large variation between studies, from 30 days to up to 21 years. The median follow-up time was 2.5 years (IQR 4.4).

Most of the studies investigated a large number of potential confounding factors ( table 1). All studies working at the level of individual patients included some measure of health status including LACE index, comorbidities, previous healthcare usage and other measures. Most studies looked at age and sex and 14 (63.6%) used a measure of deprivation, social status or income.

Results of individual studies

Of the 22 studies, 18 (81.8%) showed that greater continuity of care was significantly associated with lower mortality. Of these, 16 (72.7% of the 22) were with lower all-cause mortality ( table 2). Two studies found no association of greater continuity of care with subsequent mortality during 17 or following 16 a hospital stay. One study found that continuity was not significantly associated with mortality except in general practices in the least deprived areas. 32 One study 13 investigated a range of continuity measures. They found that all insurance claims-based measures showed that higher levels of continuity were associated with higher mortality rates but greater continuity as reported by patients was associated with reduced mortality. This is the only study showing any association of increased continuity with increased mortality.

Due to the heterogeneity of study continuity and mortality measurements, it was not possible to combine them to produce an estimate of effect size; however, table 2 shows the risk ratio, OR or HR from individual studies where available.

Risk of bias within studies

Using the Newcastle-Ottawa Scale, 36 all 22 studies were rated as high quality, with nine 10 studies (40.9%) gaining maximum scores from both reviewers independently ( table 1, supplementary table). No study was scored less than 7 out of 9 by any reviewer. As all these studies were cohort or cross-sectional studies, they tested for associations only. However, most involved statistical analyses for a wide range of potential confounding factors ( table 1).

The specific bias of reverse causality between the healthcare-related events that might occur before death was discussed in 14 (63.6%) of the studies. Four cohort studies did not discuss reverse causality. 14 24 27 31 However, all of the studies included some measure of health/disease status as a potential confounding factor and some included several detailed measures of these in their models.

Five of the studies had a design which meant there was no overlap between the time for continuity measurement and the period during which deaths were counted. 13 20 22 28 30 Seven studies have complete 14 16 21 23 28 29 31 and four partial overlap of these periods. 17 19 24 25 Five studies included additional analyses which either eliminated the overlap 23 or introduced a lag time 19 21 26 28 between continuity and mortality measurement periods. In each of these additional analyses, continuity was still found to be significantly associated with mortality. One long-term study 24 calculated survival from the date of the last continuity measurement and stratified by the length of time in the study. Five studies 19 21 25 28 29 used their continuity score as a time-dependent variable in the model.

Risk of bias across studies

There is a risk of publication bias. It may be that reports showing no effect are less likely to be published. However, two showed no association. In two, mortality was not the primary outcome and in six, it was part of a composite outcome. For 13 studies, mortality was not the only outcome. In 10 studies, the association of two or more factors, including doctor continuity of care, with outcomes was tested. Continuity and mortality as exposure and outcome, respectively, are reported in a range of studies, including where testing this association was not the primary aim.

Principal findings

In a substantial majority of studies (18, 81.8%) meeting the selection criteria, higher levels of continuity of care with doctors were associated with lower mortality rates. Two others, finding no significant association, had very short timescales for measurement of continuity, to the extent that the strength of any patient-doctor relationship was potentially questionable. Another study showing no significant association with all-cause mortality was cross-sectional, and the measurement methods related to questions on a national survey about seeing a particular general practitioner, again not necessarily indicative of a strong patient-doctor relationship.

One study 8 found that for claims-based measures of continuity, increased mortality was associated with higher levels of continuity of care. However in the same study, higher levels of patient-reported continuity were associated with lower mortality rates. This emphasises the interpersonal relationship between patient and doctor as claims-based measures only give numbers of contacts and do not directly measure the quality of the relationship.

The effect sizes were generally small ( table 2) but these were in the same range as some treatment effects, as very large, repeatable effects on mortality are rare. 53 In addition, for some studies included in this review, effect sizes were calculated using very small increments in the continuity measure.

Strengths and weaknesses of the evidence

All the studies found investigating the association of continuity of care with mortality were observational in nature, although the majority were high-quality cohort studies including three prospective cohort studies. The issue of reverse causality applies to all the evidence presented here. This could bias an association between continuity of care and mortality in either direction. As patient health worsens when approaching death, continuity of care may deteriorate for many reasons, for example, patients moving areas to accommodate increased health needs, the need to see more specialists or a loss of ability to obtain and attend appointments. Alternatively, deterioration of health could lead to a concerned doctor ensuring that the patient receives more continuity of care. For the cross-sectional studies, there is also a potential for confounding due to practice-level factors.

There have been randomised controlled trials into continuity of care but none on existing relationships or lasting longer than a year and none with mortality as an outcome. 4-6 Observational studies which control rigorously for confounding factors and have a design aimed at limiting the impact of reverse causality are the best evidence available.

Of the 16 cohort studies finding an association of higher continuity with lower mortality, most studies attempt to at least partially account or control for reverse causality in their study design or analysis. Most controlled for differences in health status and risk factors. Some carried out analyses measuring continuity and mortality in separate years, or with a lag. This method, particularly the lag between measurements, should help to minimise bias caused by rapid worsening prior to death. However, four cohort studies showing this association 14 24 27 31 did not discuss this kind of reverse causality although one 24 nevertheless made several adjustments for health status and calculated survival from the date of the last continuity measurement. Measuring continuity and mortality over separate time periods is also one way of eliminating the potential bias caused by those who survived longer having more time to accrue continuity (time-dependent bias). Another way of reducing this is to model continuity as a time-dependent variable which was the case in five studies. 19 21 25 28 29

All studies included were rated as high quality, using the Newcastle-Ottawa Scale.

Several of the articles reported on studies using very large cohorts. The studies came from a number of different countries with different healthcare systems and cultures. Continuity of care in the studies included that received from specialist as well as generalist doctors, showing that the effect is not limited to one branch of medicine or health system.

As continuity research is an emerging field, no consensus on the best way to measure it has been reached. The measure used most was the UPC Index which does not take into account the total number, frequency or sequence of visits. 54

Doctors have been studied as a discrete category in numerous studies, and data systems usually allow them to be separately studied. The group studied included family doctors/general practitioners, physicians and psychiatrists so was already heterogeneous so expanding this to other professional groups would have complicated interpretation. As doctors are the most highly trained health professionals with the most influence over decisions, it is reasonable to assume that if interpersonal contact affects mortality, it is most likely to occur with doctors. Therefore, we eliminated articles, some with significant reductions in mortality, that measured continuity in relation to mixed profession teams or to other health professionals. 35 43-49 This is the first systematic review investigating whether continuity of doctor care is associated with reduced mortality. We expect this to encourage studies with different selection criteria; for example, for continuity with other healthcare professionals.

Possible mechanisms and implications

This review, finding that increased receipt of continuity of care is associated with reduced mortality, comes after it has been shown that continuity of care is associated with multiple benefits for patients. 9-12 It therefore fits well with such earlier work. It is only recently that large databases and long-term cohort studies have made effective investigation into the links between continuity and mortality possible.

These known associations suggest possible mechanisms in that greater uptake of evidence-based preventative medicine such as immunisations as well as better concordance with treatments is likely to reduce mortality. Continuity of care is associated with patients perceiving that the doctor has become more responsive. 55Patients then disclose more and medical management is more likely to be tailored to the needs of the patient as a person. The increased patient satisfaction may also be associated with an 'optimism' boost to health. 56 We have previously suggested that 'doctors tend to overestimate their effectiveness when consulting with patients they do not know, and underestimate their effectiveness when consulting with patients they know'. 57

The cumulative impact of these multiple gains may then be reflected in reduced mortality.

Historically, continuity of care has been considered a feature of the practice of medical generalists and featured in the job descriptions of the general practitioner. 58 59 Recent studies included in this review found that continuity was associated with reduced mortality with specialist physicians, 22 28 psychiatrists 19 and surgeons 20 too.

Although this evidence is observational, with 18 of the 22 studies showing significant reductions in mortality with continuity of doctor care, the clear preponderance of evidence is in favour of the association. Three studies showed no significant association and one 13 had mixed results but no study exclusively showed an association of higher continuity of care with higher mortality rates. Although there are difficulties in carrying out controlled trials on this subject, a few, with interventions to increase continuity of care, have been successful, 4-6 and this could be attempted more widely. The presence of this association in nine countries, across three continents, and in very different populations and healthcare systems implies a basic human effect. 60 The policy implication as many studies noted is prioritising continuity of care.

For 200 years, medical advances have been mainly technical and impersonal which has reduced attention to the human side of medicine. This systematic review reveals that despite numerous technical advances, continuity of care is an important feature of medical practice, and potentially a matter of life and death.

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Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality

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Objective Continuity of care is a long-standing feature of healthcare, especially of general practice. It is associated with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. This review aims to examine whether there is a relationship between the receipt of continuity of doctor care and mortality.

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Starfield contribution of primary care

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Abstract

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

Keywords: Primary care, health outcomes, population health

The term primary care is thought to date back to about 1920, when the Dawson Report was released in the United Kingdom. That report, an official "white paper," mentioned "primary health care centres," intended to become the hub of regionalized services in that country. Although primary care came to be the cornerstone of the health services system in the United Kingdom as well as in many other countries, no comparable focus developed in the United States. Indeed, the formation of one after another specialty board in the early decades of the 20th century signaled the increasing specialization of the U.S. physician workforce ( Stevens 1971). The GI Bill of Rights, which supported the further training of physicians returning from service in World War II, helped increase the specialization of many who had been general practitioners (generalists) before the war. At that time, general practitioners were physicians who lacked additional training after graduation from medical school, apart from a short clinical internship.

Concerned that the survival of generalist physicians would be threatened by the disproportionate increase in the supply of specialists in the United States-to the detriment of generalist practice-family physicians, working with international colleagues, established standards for credentialing the new "specialty" of family practice. Thus, in the 1960s and 1970s, longer postgraduate training became part of generalist physicians' preparation for practice. This recognition of a "specialty" of primary care, which, in the United States, covered general internal medicine as well as general pediatrics, resulted in two reports from the Institute of Medicine (IOM) ( Donaldson et al. 1996; IOM 1978). These reports defined primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." This definition is consistent with at least two international reports ( WONCA 1991; World Health Organization 1978) and has been used to measure the four main features of primary care services: first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere. Primary care is assessed as "good" according to how well these four features are fulfilled. For some purposes, an orientation toward family and community is included as well ( Starfield 1998).

Despite the greater recognition of the importance of primary care to health services systems ( World Health Organization 1978, 2003), professionals have recently called for increasing even further the supply of specialist physicians in the United States ( Cooper et al. 2002). Compared with other industrialized nations, the United States already has a surplus of specialists, but not of primary care physicians. On the basis of the studies reviewed in this article, we believe that health of the U.S. population will improve if this maldistribution is corrected. Specifically, a greater emphasis on primary care can be expected to lower the costs of care, improve health through access to more appropriate services, and reduce the inequities in the population's health.

We first review the evidence concerning the relationship between primary care and health, using three different measures of primary care. The effect of health policy on primary care and health can also be determined by between-country comparisons, which we summarize next. We then consider the impact of primary care in reducing disparities in health across population groups. After a section on cost considerations, we discuss why primary care would be expected to have a beneficial effect on health. We then look at the analyses' limitations and discuss the likely nature of primary care in the future in accordance with the policy implications of this evidence.

Reviewing the Evidence

We used research on the effects of primary care on health from studies of the supply of primary care physicians, studies of people who identified a primary care physician as their regular source of care, and studies linking the receipt of high-quality primary care services with health status. These three lines of evidence represent a progressively stronger demonstration that primary care improves health by showing, first, that health is better in areas with more primary care physicians; second, that people who receive care from primary care physicians are healthier; and, third, that the characteristics of primary care are associated with better health. We used three systematic literature reviews of primary care ( Atun 2004; Engstrom, Foldevi, and Borgquist 2001; Health Council of the Netherlands 2004), supplemented by our own compilation of articles in major national and international general medical journals. We concentrated on publications written in English and mainly on studies from the United States (which accounted for most of them).We did, however, include studies from other countries if they addressed primary care, as measured by at least one of the three types of studies. A study's inclusion or exclusion did not depend on its findings. Rather, the only criterion for inclusion was a clear conceptualization of primary care, systematic data collection and analysis, and comparison populations. Several studies in the systematic literature reviews, although uniformly favorable to primary care, did not meet these criteria and therefore were excluded.

Primary Care and Health

Health Outcomes and the Supply of Primary Care Physicians

As a group, these studies covered a variety of health outcomes: total and cause-specific mortality, low birth weight, and self-reported health. They examined the relationship between the supply of primary care physicians and health at different levels of geographic aggregation (state, county, metropolitan, and nonmetropolitan regions); controlled for various population characteristics (such as income, education, and racial distribution); and used several different analytic approaches (standard regressions, path analyses) in individual years (cross-sectional) as well as over time (longitudinal).

The number of primary care physicians per 10,000 population is the measure of "supply." Primary care physicians include family and general practitioners, general internists, and general pediatricians. These three types of physicians constitute the primary care physician workforce and have been shown to provide the highest levels of primary care characteristics in their practices ( Weiner and Starfield 1983).

Studies in the early 1990s ( Shi 1992, 1994) showed that those U.S. states with higher ratios of primary care physicians to population had better health outcomes, including lower rates of all causes of mortality: mortality from heart disease, cancer, or stroke; infant mortality; low birth weight; and poor self-reported health, even after controlling for sociodemographic measures (percentages of elderly, urban, and minority; education; income; unemployment; pollution) and lifestyle factors (seatbelt use, obesity, and smoking). Vogel and Ackerman (1998) subsequently showed that the supply of primary care physicians was associated with an increase in life span and with reduced low birth-weight rates.

Other studies added sophistication to these early studies by examining the relationship between primary care and health after considering other potentially confounding characteristics. One of these confounders was income inequality, or the extent to which income is concentrated in certain social groups rather than being equitably distributed. In 1999, Shi and colleagues reported that both primary care and income inequality had a strong and significant influence on life expectancy, total mortality, stroke mortality, and postneonatal mortality at the state level. They also found smoking rates to be related to these outcomes, but the effect of the primary care physician supply persisted after they controlled for smoking ( Shi et al. 1999). A later study confirmed these findings, this time using self-assessed health as the health outcome ( Shi and Starfield 2000). These relationships remained significant after controlling for age, sex, race/ethnicity, education, paid work (employment and type of employment), hourly wage, family income, health insurance, physical health (SF-12), and smoking.

Additional studies examined the influence of the supply of primary care physicians at the state level while also taking into account the supply of specialist physicians. These analyses found, in the same year as well as in time-lagged (between 1985 and 1995) analyses, that the supply of primary care physicians was significantly associated with lower all-cause mortality, whereas a greater supply of specialty physicians was associated with higher mortality. When the supply of primary care physicians was disaggregated into family physicians, general internists, and pediatricians, only the supply of family physicians showed a significant relationship to lower mortality ( Shi et al. 2003a).

Mortality attributed to cerebrovascular stroke also was found to be influenced by the supply of primary care physicians. Using 11 years of state-level data and adjusting for income inequality, educational level, unemployment, racial/ethnic composition, and percentage of urban residents, the supply of primary care physicians remained significantly associated with reduced mortality and even wiped out the adverse effect of income inequality ( Shi et al. 2003b).

Consistent with these findings for total and cause-specific mortality, the reduction in low birth weight at the state level was significantly associated with the supply of primary care physicians in the concurrent year as well as after one-, three-, and five-year lag periods ( Shi et al. 2004). A greater supply of primary care physicians was associated with lower infant mortality as well and persisted after controlling for various socioeconomic characteristics and income inequality.

County-level analyses confirmed the positive influence of an adequate supply of primary care physicians by showing that all-cause mortality, heart disease mortality, and cancer mortality were lower where the supply of primary care physicians was greater. When urban areas (counties including a city with at least 50,000 people) and nonurban areas were examined separately ( Shi et al. 2005b), nonurban counties with a greater number of primary care physicians experienced 2 percent lower all-cause mortality, 4 percent lower heart disease mortality, and 3 percent lower cancer mortality than did nonurban counties with a smaller number of primary care physicians. In urban areas, however, the relationship appeared more complex, possibly resulting from the lesser degree of income inequality and the greater racial differences in urban areas. A study of premature mortality (mortality before age 75) in U.S. metropolitan, urban, and rural areas found inconsistent relationships to the supply of primary care physicians, possibly owing to a statistical instability in the way in which the supply of physicians was categorized, which was inappropriate for areas with great variability in both the supply and the population size ( Mansfield et al. 1999).

Analyses conducted in counties in the state of Florida used cervical cancer mortality as the health outcome. Controlling for a variety of county-level characteristics (percentage of whites, low educational level, median household income, percentage of married females, and urban/nonurban), each one per 10,000 population increase in the supply of family physicians was associated with a decrease in mortality of 0.65 per 100,000 population. That is, a one-third increase in the supply of family physicians was associated with a 20 percent lower mortality rate from cervical cancer. The positive effect of primary care was also found in the significant relationship between reduced mortality and the supply of general internists, but not the supply of obstetrician-gynecologists ( Campbell et al. 2003).

The relationship between primary care physician supply and better health is not limited to studies in the United States. In England, the standardized mortality ratio for all-cause mortality at 15 to 64 years of age is lower in areas with a greater supply of general practitioners. (In England, pediatricians and internists are not considered, and do not function as, primary care physicians.) Each additional general practitioner per 10,000 population (a 15 to 20 percent increase) is associated with about a 6 percent decrease in mortality ( Gulliford 2002). A later study ( Gulliford et al. 2004) found that the ratio of general practitioners to population was significantly associated with lower all-cause mortality, acute myocardial infarction mortality, avoidable mortality, acute hospital admissions (both chronic and acute), and teenage pregnancies, but the statistical significance disappeared after controlling for socioeconomic deprivation and for partnership size, which the authors interpreted as suggesting that the structural characteristics of primary care practices may have had a greater impact on health outcomes than did the mere presence of primary care physicians.

The supply of general practitioners also has high salience for in-hospital mortality; that is, it is more closely associated with lower in-hospital standardized mortality than is the total number of physicians per 100 hospital beds ( Jarman et al. 1999).

In summary, the studies consistently show a relationship between more or better primary care and most of the health outcomes studied. Primary care was associated with improved health outcomes, regardless of the year (1980-1995), after variable lag periods between the assessment of primary care and of health outcomes, level of analysis (state, county, or local area), or type of outcome as measured by all-cause mortality, heart disease mortality, stroke mortality, infant mortality, low birth weight, life expectancy, and self-rated health. All but a few studies found this effect for cancer mortality. The magnitude of improvement associated with an increase of one primary care physician per 10,000 population (a 12.6 percent increase over the current average supply) averaged 5.3 percent. The results of these studies suggest that as many as 127,617 deaths per year in the United States could be averted through such an increase in the number of primary care physicians ( Macinko, Starfield, and Shi 2005).

Patients' Relationship to Primary Care Facilities and Providers

Because a greater number of primary care physicians does not necessarily mean that all people in the area have greater access to or receipt of primary care services, analyses considering people's relationships to or experiences with a primary care practitioner are helpful to determining the association between primary care and health outcome. Thus the second line of evidence for the positive impact of primary care on health comes from comparing the health of people who do or do not have a primary care physician as their regular source of care.

A nationally representative survey showed that adult U.S. respondents who reported having a primary care physician rather than a specialist as their regular source of care had lower subsequent five-year mortality rates after controlling for initial differences in health status, demographic characteristics, health insurance status, health perceptions, reported diagnoses, and smoking status ( Franks and Fiscella 1998). That is, people who identify a primary care physician as their usual source of care are healthier, regardless of their initial health or various demographic characteristics.

U.S. populations served by community health centers, which are required to emphasize primary care as a condition for federal funding, are healthier than populations with comparable levels of social deprivation receiving care in other types of physicians' offices or clinics ( O'Malley et al. 2005). People receiving care in community health centers receive more of the indicated preventive services than does the general population ( Agency for Healthcare Research and Quality 2004). A comparison of rural patients receiving care in these community health centers with patients receiving care in other types of facilities showed that despite being sicker, they are significantly more likely to have received a Pap smear in the previous three years and to have been vaccinated against pneumococcal infection and less likely to have low-birth-weight babies ( Regan et al. 2003).

In some health systems, both in the United States and abroad, people normally go to their primary care physician before seeking care elsewhere (such as from another type of physician). Spain passed a law in the mid-1980s that strengthened primary care by reorganizing services to better achieve the main features of primary care, which led to the establishment of a national program of primary health care centers. The impact of this reform on health was evaluated after ten years by examining mortality rates for some major causes of death ( Villalbi et al. 1999). Death rates associated with hypertension and stroke fell most in those areas in which the reform was first implemented. There even were fewer deaths from lung cancer in those areas with primary care reform than in other areas. Health outcomes that would not be expected to be influenced by primary care, for example, perinatal mortality, did not differ across the areas.

Outcomes of care after surgery in Canada also were shown to be better when care was sought from a primary care physician who then referred children to specialists for recurrent tonsillitis or otitis media, compared with self-referral to a specialist ( Roos 1979). The referred children had fewer postoperative complications, fewer respiratory episodes following surgery, and fewer episodes of otitis media after surgery, thus implying that specialist interventions were more appropriate when patients were referred from primary care.

Finally, we note that Cuba and Costa Rica, which reformed their health systems to provide people with a source of primary care, now have much lower infant mortality rates than do other countries in Latin America. In Cuba, infant mortality rates now are on a par with those in the United States ( PAHO 2005; Riveron Corteguera 2000; Waitzkin et al. 1997).

The findings from studies of the impact of actually receiving care from a primary care source consistently show benefits for a variety of health and health-related outcomes.

How Well the Characteristics of Primary Care Are Achieved

As we noted earlier, until recently primary care could be assessed only by determining the type of physician who provided it: family physicians, general internists, and general pediatricians in the United States; and family physicians or general practitioners in most other industrialized countries. The intensive examination of criteria for the designation of "primary care" in the most recent half century encouraged the development of tools to assess the adequacy of those health delivery characteristics that together define the practice of primary care. This development then enabled us to examine the extent to which the receipt of better primary care is associated with better health.

Using these new methods, several studies have demonstrated a positive association between the adequacy of the features of primary care and the provision of preventive services. A cross-sectional study using a representative sample of 2,889 patients in Ohio evaluated the aforementioned four attributes of primary care for their relationship to the delivery of preventive services. After controlling for the patients' age, race, health, and insurance in the hierarchical linear regression model (HLM), each of the measured primary care attributes was significantly associated with patients' being up to date on screening, immunization, and health habit-counseling services ( Flocke, Stange, and Zyzanski 1998). According to another study, adolescents with the same regular source of care for preventive and illness care (one indication that the source is focused on providing primary care) were much more likely to receive the indicated preventive care and less likely to seek care in emergency rooms ( Ryan et al. 2001).

The positive impact of primary care also was shown by comparing the self-assessed health of those who received better primary care (as assessed by the health delivery characteristics of primary care) with those who reported less adequate primary care. Among those who reported better primary care, more than 5 percent fewer people reported poor health and 6 percent fewer reported depression than did people experiencing less adequate primary care. Considering only those who reported the best primary care experiences, 8 percent fewer reported poor health, and more than 10 percent fewer reported feeling depressed, compared with those who received less adequate primary care ( Shi et al. 2002).

Studies in two different areas of Brazil confirmed the relationship between the adequacy of primary care delivery characteristics and self-reported health. In a study in Petropolis, Macinko, Almeida, and Sa (2005) showed that patients who had better primary care experiences were more likely to report better health, even after adjusting for other salient characteristics such as their age, whether or not they had a chronic illness or a recent illness, household wealth, educational level, and the type of facility in which they received their care. Using parents' reports of their children's primary care, Erno Harzheim and colleagues confirmed these findings in a study conducted in Porto Alegre (Harzheim 2005, personal communication).

International Comparisons

International comparisons extended our examination of the impact of primary care according to the achievement of its characteristics. Studies of the characteristics of different health systems were particularly useful because they enabled us to assess the impact of various policy characteristics on the practice and outcomes of primary care. Three studies, one using data from the mid-1980s and two from a decade later, demonstrated not only that countries with stronger primary care generally had a healthier population but also that certain aspects of policy were important to establishing strong primary care practice.

The first study examined the association of primary care with health outcomes through an international comparison conducted in 11 industrialized countries ( Starfield 1991, 1994). Each country's primary care was rated according to the four main characteristics of primary care practice: first-contact care, person-focused care over time, comprehensive care, and coordinated care, as well as family orientation and community orientation. Policy characteristics were the attempts to distribute health services resources equitably (according to the extent of health needs in different areas of the country); universal or near-universal financial coverage guaranteed by a publicly accountable body (government or government-regulated insurance carriers); low or no copayments for health services; percentage of physicians who were not primary care physicians; and professional earnings of primary care physicians relative to those of other specialists. (Operational definitions of these indicators and the method of scoring them are described in Starfield 1998.) The first important finding is that the score for the practice characteristics was highly correlated with the score for the policy characteristics. That is, the adequate delivery of primary care services was associated with supportive governmental policies. The second finding is that those countries with low primary care scores as a group had poorer health outcomes, most notably for indicators in early childhood, particularly low birth weight and postneonatal mortality.

A more recent comparison, with 13 countries and an expanded set of indicators of both primary care policy characteristics and health outcomes, also showed better health outcomes for the primary care-oriented countries even after controlling for income inequality and smoking rates, most significantly for postneonatal mortality ( r = .74, p < .001) and rates of low birth weight ( r = .38, p < .001). Countries with weak primary care also performed less well on most major aspects of health, including mental health, such as years of potential life lost because of suicide ( Starfield and Shi 2002). The positive impact of primary care orientation on low birth-weight rates may reflect a beneficial effect of primary care on mothers' health before pregnancy ( Davey Smith and Lynch 2004; Starfield and Shi 2002). The characteristics of primary care practice present in countries with high primary care scores and absent in countries with low primary care scores were the degree of comprehensiveness of primary care (i.e., the extent to which primary care practitioners provided a broader range of services rather than making referrals to specialists for those services) and a family orientation (the degree to which services were provided to all family members by the same practitioner). The most consistent policy characteristics were the government's attempts to distribute resources equitably, universal financial coverage that was either under the aegis of the government or regulated by the government, and low or no patient cost sharing for primary care services ( Starfield and Shi 2002). The latter two were studied and confirmed by Or (2001).

The positive contributions of primary care to health also were found in a much more extensive time-series analysis of 18 industrialized countries, including the United States ( Macinko, Starfield, and Shi 2003). The stronger the country's primary care orientation (as measured by the same scoring system as in the earlier international comparison) was, the lower the rates were of all-cause mortality, all-cause premature mortality, and cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease. This relationship held even after controlling for various system characteristics (GDP per capita, total physicians per 1,000 population, percentage of elderly people) and population characteristics, including the average number of ambulatory care visits, per capita income, alcohol consumption, and tobacco consumption. The analyses estimated that increasing a country's primary care score by five points (on a 20-point scale) would be expected to reduce premature deaths from asthma and bronchitis by as much as 6.5 percent and that the reduction in premature mortality for heart disease could be as high as 15 percent.

Data from this study were analyzed as well to ascertain the robustness of primary care scores over time. The average primary care score increased by nearly one point from the 1970s to the 1990s. Countries that performed well in the 1970s remained high performers in each succeeding decade. When countries were divided into high and low performers (above or below the mean for each decade), no country crossed the threshold from low to high or from high to low, but the score of some countries changed. One country's score fell over time; Germany lowered access to ambulatory care services by imposing higher copayments, thus lowering its overall primary care score ( OECD 2001). In general, policy changes over time paralleled improvements in primary care practice. For example, in the late 1980s and early 1990s, Spain strengthened its primary care by moving to a tax-based financing system, improving its geographic allocation of funds, and increasing the supply of family physicians as well as developing primary health care centers that improved integration, family orientation, coordination of care, and health promotion services ( Larizgoitia and Starfield 1997). The United States' score rose slightly over time, almost entirely resulting from the greater participation of Americans in health maintenance organizations (HMOs), which tend, on average, to use a higher percentage of primary care practitioners ( Weiner 2004) and have (at least among the not-for-profit HMOs) a tradition of community involvement ( Stevens and Shi 2003).

Primary Care and Disparities in Health Outcomes

Both the World Health Organization and many countries (including the United States) have recognized the existence of marked disparities (inequities) in health across population subgroups and have identified reductions (and, for the United States, even elimination) of these as a priority ( Sachs and McArthur 2005; U.S. Department of Health and Human Services 2000). In reviewing the impact of primary care on reductions in disparities in health, we looked at studies of physician supply, studies of the association with a primary care physician, and studies of the receipt of services that fulfilled the criteria for primary care delivery.

Higher ratios of primary care physicians to population are associated with relatively greater effects on various aspects of health in more socially deprived areas (as measured by high levels of income inequality). Areas with abundant primary care resources and high income inequality have a 17 percent lower postneonatal mortality rate (compared with the population mean), whereas the postneonatal mortality rate in areas of high income inequality and few primary care resources was 7 percent higher. For stroke mortality, the comparable figures were 2 percent lower mortality where the primary care resources were abundant and 1 percent higher where the primary care resources were scarce (calculated from data in Shi et al. 1999). These findings are even more striking in the case of self-reported health. Income inequality and primary care were significantly associated with self-rated health, but the supply of primary care physicians significantly reduced the effects of income inequality on self-reported health status ( Shi and Starfield 2000). People in high-income-inequality areas were 33 percent more likely to report fair or poor health if the primary care resources were few (calculated from data in Shi and Starfield 2000).

As in state-level analyses, the adverse impact of income inequality on all-cause mortality, heart disease mortality, and cancer mortality was considerably diminished where the number of primary care physicians in county-level analyses was high ( Shi et al. 2005a).

The supply of primary care physicians in the U.S. states has a larger positive impact on low birth weight and infant mortality in areas with high social inequality than it does in areas with less social inequality ( Shi et al. 2004).

Eleven years of state-level data found the supply of primary care physicians to be significantly related to lower all-cause mortality rates in both African American and white populations, after controlling for income inequality and socioeconomic characteristics (metropolitan area, percentage of unemployed, and educational levels). In these state-level analyses, the supply of primary care physicians had a greater positive impact on mortality among African Americans than among whites. The inclusions of both the supply of primary care physicians and sociodemographic characteristics eliminated the negative impact of income inequality. The association between a greater supply of primary care physicians and lower total mortality was found to be four times greater in the African American population than in the white majority population, indicating a reduction in racial disparities in mortality in the U.S. states ( Shi et al. 2005c). But when exploring further the relationship between the supply of primary care physicians and health outcomes in African American and white populations in metropolitan areas of the United States, both the supply of primary care and income inequality were significantly associated with total mortality rates in the white population, whereas only income inequality maintained its significant relationships in African American populations ( Shi and Starfield 2001). The authors interpreted this finding as suggesting that in many urban areas, a great supply of primary care physicians does not ensure certain population subgroups' access to primary care; they may receive their care in places such as hospital clinics and emergency rooms, which do not emphasize primary care.

The equity-related effect of having a good primary care source also was found in the study that examined the degree of primary care-oriented services that people received. Good primary care experiences were associated with reductions in the adverse effects of income inequality on health, with fewer differences in self-rated health between higher and lower income-inequality areas where primary care experiences were stronger ( Shi et al. 2002). Although similar in the direction of effect, the relationship to "feeling depressed" was not statistically significant.

In county-level analyses that stratified urban areas by race, the supply of primary care physicians had a strong and significant influence on white mortality in both low- and high-income-inequality areas, but only a weak association with African American mortality in low-income-inequality areas and no significant association in high-income-inequality areas ( Shi et al. 2005b).

Thus, the U.S. studies showed that an adequate supply of primary care physicians reduced disparities in health across racial and socioeconomic groups. Multivariate analyses controlling for individual, community, and state-level characteristics provided strong evidence for the association of primary care with fewer disparities in several aspects of health.

These conclusions are buttressed by a study comparing the type of place where care is received. Disparities in low-birth-weight percentages between the majority white and African American infants are fewer in infants of mothers receiving care in primary care-oriented community health centers, compared with the population as a whole. In both white and African American populations in both urban and rural areas in the United States, the rates of low birth weight were lower, in both absolute numbers and ratios of rates, where the source of care was a community health center ( Politzer et al. 2001).

A study of civil servants in the United Kingdom, where access to primary care physicians is universal, found that socioeconomic differences in coronary heart disease mortality were not a result of differences in cardiac care ( Britton et al. 2004). Another exploration of the effect of primary care found that blacks in London did not have greater rates of diabetes-related lower-extremity amputation than whites did ( Leggetter et al. 2002), whereas blacks in the United States had rates two to three times higher than that in the white population. In the United Kingdom, the rates were lower in black men than in the white population, a difference wholly accounted for by lower rates of smoking, neuropathy, and peripheral vascular disease. The findings persisted even after controlling for socioeconomic differences, thus confirming other findings ( van Doorslaer, Koolman, and Jones 2004) that a health system oriented toward primary care services (such as in the United Kingdom) reduced the disparities in health care so prominent in the United States ( Agency for Healthcare Research and Quality 2004).

Primary care programs aimed at improving health in deprived populations in less developed countries succeeded in narrowing the gaps in health between socially deprived and more socially advantaged populations. A matched case-control study in Mexico ( Reyes et al. 1997) found that some aspects of primary care delivery had an important independent effect on reducing the odds of children dying in socially deprived areas. These processes included adequate referral mechanisms, continuity of care (being seen by the same provider at each visit), and being attended in a public facility designed to provide primary care. A study in Bolivia ( Perry et al. 1998) found that a community-based approach to planning primary health care services in socially deprived areas lowered the mortality of children under age five compared with adjacent similar areas or the country as a whole.

The Costa Rican primary care reforms, which were instituted first in the most socially deprived areas, illustrate the importance of primary care in reducing health disparities. These reforms included transferring the responsibility for providing health care from the Ministry of Health to the Costa Rican Social Security Fund (CCSS), expanding the number of primary care facilities-particularly in underserved areas-and reorganizing primary care into "integrated primary care teams" or EBAIS (equipos básicos de atención integral en salud), which consist of teams of health professionals assigned to a geographic region covering about 1,000 households ( Rosero-Bixby 2004b). By 1985, Costa Rica's life expectancy reached 74 years, and infant mortality rates fell from 60 per 1,000 live births in 1970 to 19 per 1,000 live births, levels comparable to those in more developed countries. The improvements in primary health care were estimated to have reduced infant mortality by between 40 percent and 75 percent, depending on the particular study ( Haines and Avery 1982; Klijzing and Taylor 1982; Rosero-Bixby 1986). For every five additional years after primary health care (PHC) reform, child mortality fell by 13 percent, and adult mortality fell by 4 percent. The study's quasi-experimental nature provided evidence of the power of PHC policies and provision of services to improve health, above and beyond improvements in social and economic indicators (which the longitudinal analyses controlled for) ( Rosero-Bixby 2004a).

Studies in other developing countries show the considerable potential of primary care to reduce the large disparities associated with socioeconomic deprivation. In seven African countries, the wealthiest 20 percent of the population receives well over three times as much financial benefit from overall government spending as does the poorest 20 percent of the population (40 percent versus 12 percent). For primary care services, the ratio of rich to poor in the distribution of government expenditures was notably lower (23 percent to the top group versus 15 percent to the lowest group) ( Castro-Leal et al. 2000), leading one international expert to conclude that "from an equity perspective, the move toward primary care represents a clear step in the right direction" ( Gwatkin 2001,720). An analysis of preventable deaths in children concluded that in the 42 countries accounting for 90 percent of child deaths worldwide, 63 percent could have been prevented by the full implementation of primary care. The primary care interventions included integrated care addressing the very common problems of diarrhea, pneumonia, measles, malaria, HIV/AIDS, preterm delivery, neonatal tetanus, and neonatal sepsis ( Jones et al. 2003).

Except in metropolitan areas, where a greater supply of primary care physicians alone may not be associated with reductions in disparities between African Americans and whites, the findings of fewer disparities by primary care were consistent across all types of studies and were particularly marked in studies examining the actual receipt of primary care services.

Costs of Care

In addition to its relationship to better health outcomes, the supply of primary care physicians was associated with lower total costs of health services. Areas with higher ratios of primary care physicians to population had much lower total health care costs than did other areas, possibly partly because of better preventive care and lower hospitalization rates. This was demonstrated to be the case for the total U.S. adult population ( Franks and Fiscella 1998), as well as among U.S. elderly living in metropolitan areas ( Mark et al. 1996; Welch et al. 1993). Baicker and Chandra's (2004) analysis showed a linear decrease in Medicare spending along with an increase in the supply of primary care physicians, as well as better quality of care (as measured by 24 indicators concerning the treatment of six common medical conditions). In contrast, the supply of specialists was associated with more spending and poorer care.

Care for illnesses common in the population, for example, community-acquired pneumonia, was more expensive if provided by specialists than if provided by generalists, with no difference in outcomes ( Rosser 1996; Whittle et al. 1998).

Consistent with the findings within countries, international comparisons of primary care showed that those countries with weaker primary care had significantly higher costs ( r = .61, p < .001) ( Starfield and Shi 2002).

Rationale for the Benefits of Primary Care for Health

Six mechanisms, alone and in combination, may account for the beneficial impact of primary care on population health. They are (1) greater access to needed services, (2) better quality of care, (3) a greater focus on prevention, (4) early management of health problems, (5) the cumulative effect of the main primary care delivery characteristics, and (6) the role of primary care in reducing unnecessary and potentially harmful specialist care.

1. Primary care increases access to health services for relatively deprived population groups. Primary care, as the point of first contact with health services, facilitates entry to the rest of the health system. With the exception of the United States, most industrialized countries have achieved universal and equitable access to primary health services, some of them directly provided and others through the assurance of financial coverage for visits ( van Doorslaer, Koolman, and Jones 2004). In the United States, however, socially deprived population subgroups are more likely than more advantaged people to lack a regular source of care. The evidence is striking with regard to family income, for which there are marked gradients in having a regular source of care, hovering around 80 percent for the poor and near-poor to nearly 90 percent for those in the middle income range, approaching 95 percent for those with high incomes, and increasing over time from 1999 to 2001 for mainly those with high incomes ( Agency for Healthcare Research and Quality 2004).

The principal benefit of health insurance in the United States is facilitating access to primary care ( Lillie-Blanton and Hoffman 2005; Starfield and Shi 2004). Socially deprived population groups that do not have health insurance are less likely to have a source of primary care and thus have less access to the entire health system. Over the past several decades, attempts to improve access have been mainly the expansion of eligibility for reimbursement by public funds through Medicare, Medicaid, and related programs like the State Child Health Insurance Program. Some, but not all, of these efforts have been accompanied by incentives or even mandated enrollment with a regular source of care, and disparities in identification with a regular source of care have been reduced. However, differences in the receipt of good primary care services persist ( Seid, Stevens, and Varni 2003; Shi 1999; Stevens and Shi 2002; Taira et al. 1997). Shi's national study of adults (1999) demonstrated not only differences in the likelihood of having a regular source but also (and more marked) differences in the type of that regular source, with minorities more likely to report a place rather than a person as their regular source of care; to have a specialist (other than a primary care physician) if they reported a physician as their source of care; and to experience longer delays in obtaining needed services after controlling for having a regular source of care. The same was found for children ( Newacheck, Hughes, and Stoddard 1996). Other studies show that minority children are more likely to use an emergency room as their source of care ( Weitzman, Byrd, and Auinger 1999). After controlling for having a regular source of care, there were few if any differences in reporting difficulty in obtaining needed services.

Analyses reported by Weinick and Krauss (2000) and Lieu, Newacheck, and McManus (1993) confirmed the finding of fewer or no difficulties in access to care when the source is a primary care source. Once they do have access to adequate primary care services, deprived minority groups often report better experiences with their care than the majority white population does, particularly when the studies were conducted in organized health care settings that, by design, eliminated many of the access barriers to primary care services ( Morales et al. 2001; Murray-Garcia et al. 2000; Taira et al. 1997).

In sum, one of the main functions of a primary care source is reducing or eliminating difficulty with access to needed health services.

2. The contribution of primary care to the quality of clinical care. Studies designed by specialists to compare the quality of care of specialty and generalist practices often find that specialists are better at adhering to guidelines. For example, adhering to guidelines for asthma management was better in practices of specialists dealing with asthma ( Bartter and Pratter 1996), and gastroenterologists used antibiotic therapy for helicobacter pylori earlier than generalists did (unless the generalists were in a group practice with gastroenterologists) ( Hirth, Fendrick, and Cher 1996). Most studies comparing generalists and specialists concluded that the condition-specific quality of care provided by specialists was better when the condition was in the specialist's area of special interest, using indicators of quality of care such as the performance of disease-specific preventive procedures, the performance of indicated laboratory tests for monitoring disease status, and the prescription of relevant medications ( Harrold, Field, and Gurwitz 1999).

The findings concerning the superior quality of care by specialists were not, however, confirmed by other studies. In demonstrating the effectiveness of primary care for diabetes, general practitioner (GP) diabetic clinics in the United Kingdom were found to do as well as hospital specialists in monitoring for diabetic complications ( Parnell, Zalin, and Clarke 1993). In addition, in systems in which the GPs were given additional educational support and had an organized system for recall, GPs' care of diabetic patients was better than that of specialists in hospitals. In such situations, patients of GPs had lower mortality rates and better glycemic control than did patients treated by specialists ( Griffin and Kinmonth 1998). Rates of complications, readmission to the hospital, and length of convalescence were the same after early discharge from the hospital after minor surgery, regardless of whether the care was provided by the hospital's outpatient department or general practitioners ( Kaag, Wijkel, and de Jong 1996). Moreover, the few studies planned and executed by generalists ( Donohoe 1998; Grumbach et al. 1999) concluded that the quality of care was the same or that primary care was better. These differences suggest differences in the conceptualization of appropriate "outcomes" by the two types of physicians, with specialists more concerned with specific disease-related measures and adherence to guidelines for these diseases and primary care physicians more targeted to multiple aspects of health, that is, "generic" health. Assessing generic outcomes, or quality of care other than for the particular conditions under study, is important because comorbidity is common and causes more visits to both generalists and specialists than do most specific conditions ( Starfield et al. 2003; Starfield et al. 2005a). If the interest is in patients' health (rather than disease processes or outcomes) as the proper focus of health services, primary care provides superior care, especially for conditions commonly seen in primary care, by focusing not primarily on the condition but on the condition in the context of the patient's other health problems or concerns.

In short, primary care physicians do at least as well as specialists in caring for specific common diseases, and they do better overall when the measures of quality are generic. For less common conditions, the care provided by primary care physicians with appropriate backup from specialists may be the best; for rare conditions, appropriate specialist care is undoubtedly important, as primary care physicians would not see such conditions frequently enough to maintain competence in managing them.

3. The impact of primary care on prevention. The evidence strongly shows that it is in primary care that preventive interventions are best when they are not related to any one disease or organ system. Examples of these "generic" (i.e., not limited to a particular disease or type of disease) measures are breast-feeding, not smoking, using seat belts, using smoke detectors, being physically active, and eating a healthy diet. Those U.S. states with higher ratios of primary care physicians to population have lower smoking rates, less obesity, and higher seatbelt use than do states with lower ratios of primary care physicians to population ( Shi 1994; Shi and Starfield 2000). Good primary care, as determined by peoples' ratings of its main characteristics, is positively associated with smoking cessation and influenza immunization, as shown in an ongoing 60-community study in the United States ( Saver 2002). The likelihood of disadvantaged children's making any preventive visits is much greater when their source of care is a good primary care practitioner ( Gadomski, Jenkins, and Nichols 1998).

To the extent that many preventive activities stress the early detection of specific diseases (secondary prevention), the quality of primary care (compared with specialty care) would not necessarily be expected to be better. However, the evidence suggests otherwise for common conditions that are in the purview of primary care. A greater supply of family physicians (although not necessarily internists) is associated with an earlier detection of breast cancer, colon cancer, cervical cancer, and melanoma ( Campbell et al. 2003; Ferrante et al. 2000; Roetzheim et al. 1999, 2000). Ferrante and colleagues (2000) found that each tenth-percentile increase in the supply of primary care physicians was associated with a statistically significant 4 percent increase in the odds of a diagnosis in an early (rather than late) stage. Most mammograms (87 percent) are ordered by primary care physicians ( Schappert 1994); moreover, a physician's advice to have mammograms enhances their receipt ( Breen and Kessler 1994; Campbell et al. 2003; Fox, Siu, and Stein 1994; NCI Breast Cancer Screening Consortium 1990; Roetzheim et al. 1999, 2000). Another study of differences between primary care physicians and specialists caring for patients with hypertension, non-insulin-dependent diabetes, recent myocardial infarction, or depression showed that the only preventive care procedures better performed by specialists were checks for foot ulcers and infection status in endocrinologists' diabetic patients ( Greenfield et al. 1992). Moreover, approaches to prevention in primary care practice were more generic and resulted in more improvement in patients' health status than was the case in specialty-oriented practices ( Bertakis et al. 1998). When the data were from the general community rather than from practices, having a good primary care source was the major determinant of receiving even disease-focused preventive care, consisting of blood pressure screening, clinical breast exams, mammograms, and Pap smears ( Bindman et al. 1996).

4. The impact of primary care on the early management of health problems. Another indication of the benefit of primary care is its demonstrated impact on managing health problems before they are serious enough to require hospitalization or emergency services. Several studies support this conclusion.

Shea and colleagues (1992) examined the relationship between having a primary care physician as the source of care and hospitalization for reasons that should be preventable by good primary care. Men with hypertension who were admitted to the hospital from the emergency room in a large metropolitan area were divided into two groups. One group was composed of those who were admitted for a preventable complication of hypertension; the other group was admitted for a condition unrelated to hypertension. The study found that those admitted for the preventable complication were four times more likely to lack a primary care provider than were those admitted for a condition unrelated to hypertension, even after considering other factors such as absence of health insurance, level of compliance with antihypertensive regimens, and alcohol or drug use-related problems, thus indicating that those men with a primary care provider were relatively better protected against hospitalization for a preventable complication of a common medical problem.

In the United Kingdom, each 15 to 20 percent increase in GP supply per 10,000 population was significantly associated with a decrease in hospital admission rates of about 14 per 100,000 for acute illnesses and about 11 per 100,000 for chronic illnesses, even after controlling for the degree of social deprivation in the area in which people live, their social class, ethnicity, and limiting long-term illness ( Gulliford 2002).

In the United States, rates of hospitalization for conditions that should be preventable by exposure to good primary care (ambulatory care-sensitive conditions, or ACSC) are strongly associated with socioeconomic deprivation, at least in part because socially disadvantaged populations are less likely to have a good source of primary care ( Agency for Healthcare Research and Quality 2004; Hansell 1991; Stevens and Shi 2002). In contrast, in Spain, the rates of hospitalization for these conditions were not associated with socioeconomic characteristics, indicating that the Spanish health system's primary care orientation reduced the hospitalization rates for these conditions despite social disadvantage ( Casanova, Colomer, and Starfield 1996; Casanova and Starfield 1995).

In a large multispecialty comparison of hospitalization rates, Greenfield and colleagues found that the rates of hospitalization were 100 percent higher when, compared with family physicians, the ongoing care was provided by cardiologists and 50 percent higher when it was provided by endocrinologists ( Greenfield et al. 1992).

The literature is consistent in showing that lower rates of hospitalization for ACSC are strongly associated with the receipt of primary care. Geographic areas with more family and general practitioners have lower hospitalization rates for these types of conditions, including diabetes mellitus, hypertension, and pneumonia ( Parchman and Culler 1994). Children receiving their care from a primary care source that fulfills the criteria for its main characteristics have lower hospitalization rates for these conditions as well as lower hospitalization rates overall. These findings are associated with the greater receipt of preventive care from primary care providers ( Gadomski, Jenkins, and Nichols 1998). Rates of hospital admissions of children are lower in those U.S. communities in which primary care physicians are more involved in caring for children both before and during hospitalization ( Perrin et al. 1996). Adolescents with the same regular source of care for preventive and illness care are less likely to seek care in emergency rooms ( Ryan et al. 2001). An analysis of national Medicare data showed that the elderly in the United States who are in fair or poor health are more likely to experience a potentially preventable hospitalization if they live in a county designated as a primary care shortage area ( Parchman and Culler 1999).

Only two studies failed to find a positive impact for the supply of primary care physicians and hospitalizations for conditions sensitive to primary care management. Each of the studies was conducted in only one state, New York or North Carolina ( Ricketts et al. 2001; Schreiber and Zielinski 1997). In both studies, socioeconomic characteristics were more salient, and so it is possible that in some places, the availability of more primary care physicians did not necessarily mean that deprived populations had access to them. A later study in one of those states (New York) showed that the ratio of primary care physicians to population was one of the more salient factors associated with lower levels of hospitalizations for ACSC ( Friedman and Basu 2001).

5. The accumulated contribution of primary care characteristics to more appropriate care. As noted in regard to quality of care, the beneficial effects of primary care on mortality and morbidity can be attributed, at least in part, to the focus of primary care on the person rather than on the management of particular diseases. Care focuses on the person when practitioners attend to overall aspects of the patient's health rather than to the care of his or her specific diseases; it focuses on achieving better outcomes for health in all its aspects rather than on the procedures directed at improving the processes or outcomes of care for particular conditions. Other aspects of health services delivery that are characteristic of primary care also have been associated with better health outcomes. Although an extensive review of the positive contribution of each of these characteristics is outside the scope of this review (which concerns primary care as an entity within health service systems) and has been covered elsewhere ( Starfield 1998), a brief summary of these contributions explains why primary care as a whole might have positive effects.

We noted earlier that an important element of primary care is its role as the first contact for patients when a problem develops. In a seminal article entitled "Gatekeeping Revisited-Protecting Patients from Overtreatment," Franks, Clancy, and Nutting (1992) made the case for seeing a primary care physician before seeking care from another type of physician. Having a relationship with a primary care practitioner who can serve as an initial point of contact is strongly and statistically significantly associated with less use of specialists and emergency rooms ( Hurley, Freund, and Taylor 1989; Martin et al. 1989). Continuity of care, which implies that individuals use their primary source of care over time for most of their health care needs, is associated with greater satisfaction, better compliance, and lower hospitalization and emergency room use ( Freeman and Hjortdahl 1997; Mainous and Gill 1998; Rosenblatt et al. 2000; Weiss and Blustein 1996). Previous knowledge of a patient, which reflects good continuity of care, increases the doctor's odds of recognizing psychosocial problems influencing the patient's health ( Gulbrandsen, Hjortdahl, and Fugelli 1997). Both continuity and first-contact attributes of primary care ensure greater efficiency of services in the time saved in the consultation, less use of laboratory tests, and fewer health care expenditures ( Forrest and Starfield 1996, 1998; Hjortdahl and Borchgrevink 1991; Raddish, Horn, and Sharkey 1999; Roos, Carriere, and Friesen 1998). Very short-term relationships with physicians are associated with poor outcomes. For example, veterans with a chronic disease who did not have a previous relationship with a primary care physician were randomized to receive an intervention of increased follow-up by a newly assigned nurse and a primary care physician after they were discharged from the hospital. Rehospitalization rates six months later were higher in this intervention group ( Weinberger, Oddone, and Henderson 1996), thus indicating that relationships over time are an important component of primary care. (The study did not assess rehospitalization rates for veterans who already had a primary care provider, and it may be that the assignment of such a provider to people without an existing relationship led to the discovery of conditions not previously recognized and requiring hospitalization.) At least two years of a relationship (and as many as five) are generally required for patients and practitioners to get to know each other well enough to provide optimal person-focused care ( Starfield 1998, 175). A freely chosen primary care practitioner provides better assurance of a good relationship than does assigning a practitioner ( Starfield 1998, 151). The evidence is strong regarding the benefits of an ongoing relationship with a particular provider rather than with a particular place or no place at all. People with no source of primary care are more likely to be hospitalized, to delay seeking needed and timely preventive care, to receive care in emergency departments, and to have higher subsequent mortality and higher health care costs, and they are less likely to see a physician in the presence of symptoms. People with just a place (such as a particular hospital clinic) are somewhat better off than those without a regular source of care, in that they are more likely to keep their appointments, have fewer hospitalizations and lower costs, and receive generally better preventive care. In addition, people who report a particular doctor as their regular source of care receive more appropriate preventive care, are more likely to have their problems recognized, have fewer diagnostic tests and fewer prescriptions, have fewer hospitalizations and visits to emergency departments, and are more likely to have more accurate diagnoses and lower costs of care than are either people having a particular place or people having no place at all as their regular source of care ( Starfield 1998, chap. 8).

The benefits of the other two main attributes of good primary care (comprehensiveness and coordination) are less well documented, but the existing evidence was summarized by Starfield (1998, chaps. 10 and 11).

6. The role of primary care in reducing unnecessary or inappropriate specialty care. Nearly all studies of specialist services concluded that there is either no effect or an adverse effect on major health outcomes from increasing the supply of specialists in the United States, which already has a much greater supply of such physicians than do other industrialized countries ( Starfield et al. 2005b). This evidence addresses a wide variety of population health outcomes, including all-cause (total) mortality; heart and cerebrovascular disease mortality; cancer mortality; postneonatal, neonatal, and total infant mortality; and low birth weight; as well as the early detection of various cancers, including cervical cancer, colorectal cancers, breast cancer, and melanoma (the evidence was reviewed by Starfield et al. 2005b). The evidence is also consistent that first contact with a primary care physician (before seeking care from a specialist) is associated with more appropriate, more effective, and less costly care ( Starfield 1998, chap. 7).

Other countries, most notably the United Kingdom and the Netherlands, have led the way with primary care innovations to reduce the inappropriate use of specialist services. These include making better use of information systems and video communications as well as consulting with specialists in primary care settings.

The adverse effects of seeking care directly from nonprimary care specialists have a strong theoretical basis. Since these specialists are trained in the hospital, the patients seen by specialists are not representative of the way in which patients present symptoms in community settings, because the latter have a much lower prior probability of serious illness requiring the services of a specialist. The properties of diagnostic tests (sensitivity, specificity, predictive power of a positive test) are much different in populations with a high prevalence of serious illness than they are in community settings and thus much different in specialty care than in primary care settings. The result is that specialists practicing in the community overestimate the likelihood of illness in the patients they see, with the consequently inappropriate use of diagnostic and therapeutic modalities, both of which raise the likelihood of adverse effects ( Franks, Clancy, and Nutting 1992; Hashem, Chi, and Friedman 2003; Sox 1996). Compared with other Anglophone countries, people in the United States experience more adverse effects and medical errors ( Schoen et al. 2004). This, combined with evidence concerning the adverse effects of greater supplies of specialists and estimates of the likelihood of adverse effects of medical care, may at least partly explain the United States' low ranking on health status relative to that of similarly industrialized countries.

Potential Limitations of Interpretations of Effectiveness of Primary Care

Despite the consistency of the findings from various types of studies, areas, and populations and the theoretical rationale for benefit of primary care on population health, it is possible that the results may be overinterpreted. Those countries and areas in which primary care is strongest (however measured) may be areas in which other social interventions (such as income supports and welfare policies that influence health) also are strongest. So far, the effort to identify the social policies that have a great influence on health has not been successful ( Graham and Kelly 2004).

Moreover, the mere presence of primary care physicians may not reflect the availability of primary care services to certain population groups. At least two of the reviewed analyses in urban counties showed that the supply of primary care physicians is less closely related to the health of urban African Americans than it is for urban whites or for African Americans in rural areas. This is likely due to the poorer distribution of primary care physicians in more deprived urban areas, with the consequently greater need to seek care in such places as hospital outpatient units and emergency rooms. Supporting this hypothesis are two lines of evidence. First, African Americans are more likely than whites to report having their regular source of care in a facility (such as a hospital) and to report a specialist as their regular source of care ( Shi 1999). That is, primary care physicians in urban areas tend to locate in more socially advantaged areas ( Weiner et al. 1982). As a result, hospital clinics with predominantly hospital-based physicians not trained to provide the important features of primary care become the "default" regular source of care. Second, even in the presence of adequate primary care resources, African Americans may be less likely than other racial and ethnic groups to use primary care when other resources (such as hospital clinics) are available; this has been demonstrated to be the case for the medical care of inner-city infants ( Hoffmann, Broyles, and Tyson 1997). State-level analyses are not as susceptible to this type of possible error because primary care is more evenly distributed than is specialty care ( Shi and Starfield 2001).

If the supply of primary care physicians is less closely associated with health outcomes in urban African Americans than in whites because of difficulties in access to them, the demonstrated association between supply and health outcomes may actually underestimate the potential impact of primary care services, particularly for deprived populations. Moreover, the studies that use alternative measures of primary care, including relationships with a primary care physician and studies considering the adequacy of primary care health services delivery characteristics, all confirm the conclusion that care meeting the criteria for primary care is associated with the better health of those populations receiving it, with a greater impact in more deprived populations.

Primary Care in the Future

What issues remain to be addressed in primary care to improve its contribution to the health of populations and equity in distribution of health? A pervasive U.S. focus on "access" to health services rather than on the type of health services has detracted from the need to ensure that services are provided in the most appropriate places. The existing national data health interview surveys combine various safety net providers into one group so that people receiving their care from hospital outpatient clinics are not distinguishable from those receiving care from primary care-oriented clinics. Combining primary care-focused community health centers with hospital emergency and outpatient departments as "safety net providers" masks the high positive contributions to the health of the former with the lesser primary care focus of the latter. Apart from the Community Health Center program of the federal Health Resources and Services Administration and the commitment of certain not-for-profit health care organizations to strong primary care ( Weiner 2004), little or nothing has been done to ensure that other "regular sources of care" fulfill the criteria for good primary care. In most other industrialized countries, primary care physicians are clearly distinguished from other physicians, and where people receive care is easily identified as primary care or specialty care. Greater appreciation that it is primary care that plays a major role in ensuring access to appropriate health services should provide the rationale for better distinguishing primary care from specialty care in data on the use of health services in the United States.

At the very least, primary care must be recognized as a distinct aspect of a health services system. There now are well-validated methods (e.g., see Shi, Starfield, and Xu 2001; Starfield et al. 1998) to assess both the presence and the characteristics of primary care, and all sources of data on use of health services should include at least a few of these measures. Understanding people's primary care experiences (rather than or in addition to their satisfaction), including the extent to which they receive the range of services appropriate to their needs and have the care they receive elsewhere coordinated and integrated, are important to evaluating the adequacy of health services.

In contrast to the situation in primary care, for which intensive conceptual and methodologic study over the past several decades has clarified its most important aspects, professional specialty groups in the United States have made little if any attempt to define the practice of "specialism" or the circumstances that should lead to seeking care from specialists. Referrals to specialists apparently have three functions: short-term consultation for diagnosis or management, referral for long-term management of specific illnesses, and recurrent consultation for periodic management. A study of referrals from 80 office-based family practices showed that by far the most referrals for common conditions (over 50 percent of all referrals to most types of specialists) were expected to be for a short term (less than 12 months) and that for more than 50 percent, they were for consultation only (no direct intervention) ( Starfield et al. 2002). Very little is known, however, about the relative frequency of these functions from the viewpoint of specialty practice. One report ( Hewlett et al. 2005) indicated that about 75 percent of visits to a pulmonary specialty clinic were just for "checkups," even though the patients' primary care physicians, once they had access to the specialists' reports, could just as easily perform this function and report the findings to the specialists. Such an approach to reducing the number of visits to specialists could lower the demand for a greater supply of specialists; it at least deserves to be tested. There is an urgent need for information about the indications for specialty care and about the impact on outcomes of excessive use of specialists.

Major challenges to primary care practice concern (1) recognizing and managing comorbidity, (2) preventing the adverse effects of medical interventions, (3) maintaining a high quality of the important characteristics of primary care practice, and (4) improving equity in health services and in the health of populations ( Starfield 2001).

1. Historically, principles of delivery of medical care have been based on preventing and managing specific diseases. In the current climate of evidence-based medicine, guidelines for the management of diseases are proliferating and increasingly used. The development of guidelines is generally based on evidence from the literature that certain modes of management achieve better outcomes than others do. The "gold standard" for evidence is the randomized controlled clinical trial, which generally excludes, as a requirement for participation in the trial, individuals with comorbid conditions. Comorbidity (the simultaneous presence of apparently unrelated conditions) is common in the population and is not randomly distributed. Although comorbidity becomes more common with age, it is in the young that comorbidity occurs much more frequently than expected by the chance occurrence of two or more conditions ( van den Akker et al. 1998). (That is, the frequency of illness is much greater in the old than in the young, so there is much greater likelihood that two unrelated illnesses will be found together. In the young, illness is much less common, so that it is statistically much less likely that two or more will be found together, although in fact this is the case.) Data systems should be developed that provide a much better basis for examining the distribution and nature of comorbidity in primary care; ascertainment of the impact of baseline risks on comorbidity; likelihood of responsiveness to treatment in the presence of comorbidity; and susceptibility to adverse effects of medical interventions. Moreover, the applicability to primary care of guidelines developed from randomized controlled clinical trials may be more limited than is generally thought, even apart from the issue of comorbidity ( Kravitz, Duan, and Braslow 2004; Rothwell 2005), particularly when considering the issue of disease-specific versus overall clinical end points ( Fleming 2005).

2. Primary care practitioners are in the best position to detect the occurrence of potentially adverse effects of medical interventions, particularly those stemming from drug reactions and interactions. In systems of care oriented to primary care (including some HMOs in the United States), the primary care practitioner is, by far, the most commonly seen physician, for patients with all degrees of comorbidity and for both single common conditions and comorbid conditions. Only when individual conditions are uncommon are specialists the type of physician most frequently seen, and only for that condition ( not for comorbid conditions) ( Starfield et al. 2003; Starfield et al. 2005a). Thus, primary care physicians are more likely to see the adverse events that result from their own care as well as the care of others whom the patient may see. The challenge for primary care is to establish systems to code unexpected symptoms or signs and to create information systems that could serve as early warnings of the occurrence of adverse events in persons previously subjected to particular types of interventions. It is possible that the International Classification of Primary Care (ICPC) ( Lamberts, Wood, and Hofmans-Okkes 1993), which provides a straightforward classification of problems encountered in primary care while maintaining comparability with the better known International Classification of Diseases (originally developed to code causes of death), could serve as the basis for recording and classifying these symptoms and signs in the United States, as it is already being used in several other countries.

3. Improvement in clinical quality and in performance with respect to the main features of primary care practice is a challenge for primary care practice. Although each of these features is known to confer benefits on health, the remaining issues require consideration.

To what extent can teams of practitioners provide first-contact care without interfering with the benefits of continuing interpersonal relationships between particular practitioners and patients?

Ongoing person-focused care means that care should be focused on the person rather than on the disease. Can teams of practitioners fulfill this function?

Comprehensiveness means that all problems in the population should be cared for in primary care (with short-term referral as needed), except those that are too unusual (generally a frequency of less than one or two per thousand in the population served) for the primary care practitioner or team to treat competently. How can data systems provide the information needed to decide when problems are best met in primary care, when they can be best dealt with in primary care with appropriate specialty backup, and when patients need to be seen by a specialist?

Coordination of care means that the primary care practice must integrate all aspects of care when patients must be seen elsewhere. Because 13 to 20 percent (depending on various assumptions) of an average practice population requires a referral each year, this burden is considerable. Very few health systems, even those that rate high on primary care, achieve high coordination of care, at least as measured by transfer of information from primary care physicians to specialists and vice versa. Systems to facilitate coordinating efforts are urgently needed. Lessons might be gleaned from the experiences of some health systems. For example, and despite the design limitations ( Talbot-Smith et al. 2004) of the study comparing the Kaiser-Permanente health care plan in the United States with the National Health Service in the United Kingdom ( Feachem, Sekhri, and White 2002), the lower hospitalization rates and lower resource use in the United States may well be a result of a system specifically designed to enhance coordination between primary care physicians and specialists.

4. The achievement of equity in health services and health is an imperative everywhere. Primary care is inherently a more equitable level of care than other levels of care. It is less costly (hence sparing resources that could be devoted to providing better services to more disadvantaged populations), and through its key features, it narrows disparities in health between more and less socially deprived population groups. The extent to which primary care in fact does result in more equity depends on the availability of information about the needs in the various areas in which primary care practices are located. Better information systems, at both the area and practice levels, would enhance the already-strong benefits of primary care to the health of individuals, population subgroups, and populations ( National Committee for Vital and Health Statistics 2001).

The Relevance of Policy

The relatively poor performance of the United States on major health indicators, despite per capita health care expenditures that are much higher than those of any other country, is a pressing concern for policymakers, the business community (which has, historically, paid for much of the health insurance in the country), and, ultimately, taxpayers. Efforts to improve the system to achieve better health at lower cost are rapidly becoming imperative. Primary care offers an effective and efficient approach to achieve that goal. Evidence of the benefits of a health system with a strong primary care base is abundant and consistent. These benefits are not limited to one or only a few aspects of health but, rather, extend to the major causes of death and disorders as well as to reducing disparities in health across major population subgroups, including racial and ethnic minorities as well as socially deprived adults and children.

Federally qualified community health centers (CHCs) currently serve more than 3,600 urban and rural communities, which are typically low-income inner-city or resource-poor rural communities. But they serve only one-quarter of all people living below the poverty level, one in seven people living under 200 percent of poverty level, and one of eight uninsured Americans ( Proser, Shin, and Hawkins 2005). Expansion of the CHC network well beyond the current supply is one appropriate strategy.

Other policy strategies would strengthen primary care on a broader level ( Starfield and Simpson 1993). These include (but are not limited to) changes in the method of reimbursing primary care physicians and, particularly, better reimbursement rates for primary care services for both common conditions and for the important primary care delivery characteristics. Establishing a more rational basis for referrals and improving the coordination between primary care and specialist physicians would make primary care practice more challenging and intellectually rewarding. States could encourage a better distribution of physicians (both primary care and specialists) by tailoring their licensing policies to health needs in different areas or by providing financial incentives for practicing in underserved areas, as is done in some other countries. Incentives for training primary care practitioners could be improved by reorienting federal support for graduate medical education toward training primary care physicians. Similarly, loan forgiveness for primary care practitioners could be expanded. Reducing the amount of paperwork needed to file claims and encouraging the creation of electronic medical records would greatly reduce the tedium of record keeping in practice and, at the same time, make time to improve the self-monitoring of the quality of care. Bonus payments for team practice could enhance the comprehensiveness of primary care. Special recognition of best primary care practices could enhance public recognition of the importance of primary care and its characteristics. Finally, offering more funds for research on primary care, including the support of collaborative practice-based networks ( Lanier 2005; Wasserman, Slora, and Bocian 2003), would help meet the intellectual challenges of expanding our knowledge base for the practice of both primary care and specialty care.

Acknowledgments

This work was funded in part by the Bureau of Health Professions, U.S. Department of Health and Human Services. The authors gratefully acknowledge the advice of Dr. Neil Holtzman in writing this article.

References

Baicker K, Chandra A. Medicare Spending, the Physician Workforce, and Beneficiaries' Quality of Care. Health Affairs. 2004;W4:184-97. [http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf. [PubMed] Google Scholar]

Gadomski A, Jenkins P, Nichols M. Impact of a Medicaid Primary Care Provider and Preventive Care on Pediatric Hospitalization. [http://www.pediatrics.org/cgi/content/full/101/3/e1. [PubMed] Google Scholar]

Hirth RA, Fendrick AM, Chernew ME. Specialist and Generalist Physicians' Adoption of Antibiotic Therapy to Eradicate [Helicobacter pylori Infection. Medical Care. 1996;34:1199-1204. [PubMed] Google Scholar]

Macinko J, Almeida C, Sa P. Evaluating Primary Care Services in Brazil: A Rapid Appraisal Methodology. Unpublished manuscript.

Macinko J, Starfield B, Shi L. Quantifying the Health Benefits of Primary Care Physician Supply in the United States. Unpublished manuscript. [PubMed]

Starfield B, Lemke KW, Herbert R, Pavlovich WD, Anderson G. Comorbidity and the Use of Primary Care and Specialist Care in the Elderly. Annals of Family Medicine. 2005a in press. [[PMC free article] [PubMed] Google Scholar]

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Contribution of Primary Care to Health Systems and Health

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Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system.

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Diagnostic uncertainty questionaire

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doi: 10.1111/j.1365-2753.2010.01464.x.

Affiliation

¹ Institute of General Practice, Klinikum rechts der Isar, Technische Universität München, Munich, Germany. antonius.schneider@lrz.tum.de

Abstract

Rationale, aims and objectives: Diagnostic uncertainty plays an important role in primary care. Nevertheless, the practical way how general practitioners (GPs) deal with uncertainty remains unclear. The purpose was to develop a questionnaire which describes and measures the level of action and active reasoning in dealing with uncertainty.

Methods: Raw items for the 'GP action scale' and 'GP diagnostic reasoning scale' were derived by literature research. The questionnaire was modified by focus group discussion. The final version was administered to 325 GPs. The results of the 'Dealing with uncertainty questionnaire' (DUQ) were compared with the scales of the 'Physician Reaction to Uncertainty' (PRU) questionnaire. PRU measures affective reactions to uncertainty.

Results: Item-scale correlation of the 'GP action scale' and 'GP diagnostic reasoning scale' ranged from 0.41 to 0.61 and from 0.31 to 0.53, respectively. Crohnbach's alpha for 'GP action scale' was 0.75 and for 'GP diagnostic reasoning scale' 0.62. The 'GP diagnostic action scale' was significantly positively associated with 'Anxiety due to uncertainty', 'Concern about bad outcomes' and 'Reluctance to disclose mistakes to physicians', scales of PRU. In female doctors, 'Concern about bad outcomes' correlated positively with the 'GP diagnostic reasoning scale' (0.213; P < 0.05). In male doctors, 'Anxiety due to uncertainty' correlated negatively with the 'GP diagnostic reasoning scale' (-0.163; P < 0.05).

Conclusions: Diagnostic reasoning in primary care appears as a complex process using typical primary care inherent 'heuristics'. Affective intolerance against uncertainty correlates with self-rated diagnostic activity. Affective reactions to uncertainty might influence gender-specific reactions to uncertainty in different ways.

Managing diagnostic uncertainty in primary care: a systematic critical review.

Alam R, Cheraghi-Sohi S, Panagioti M, Esmail A, Campbell S, Panagopoulou E. Alam R, et al. BMC Fam Pract. 2017 Aug 7;18(1):79. doi: 10.1186/s12875-017-0650-0. BMC Fam Pract. 2017. PMID: 28784088 Free PMC article. Review.

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national center for biotechnology information

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How do primary care doctors deal with uncertainty in making diagnostic decisions? The development of the 'Dealing with Uncertainty Questionnaire' (DUQ) - PubMed

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doi: 10.1111/j.1365-2753.2010.01464.x. 1 Institute of General Practice, Klinikum rechts der Isar, Technische Universität München, Munich, Germany. antonius.schneider@lrz.tum.de Rationale, aims and objectives: Diagnostic uncertainty plays an important role in primary care. Nevertheless, the practical way how general practitioners (GPs) deal with uncertainty remains unclear.

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Continuity of care assessment

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This calculator is designed to allow general practices to audit the levels of continuity of patient care provided in their practice. It is intended to support the RCGP Continuity of Care Toolkit and the RCGP policy on Promoting Continuity of Care in General Practice

The calculator is provided as a service to general practices. However we are unable to provide any support in its use.

Please download and read the first page of the instructions before you try to download or use the Continuity Calculator.

EMIS users only: Search template for EMIS web for consultation data - right click emiscontinuityaudit.xml and 'save link as' or 'save target as' to save the file: 'emiscontinuityaudit.xml' in 'My Documents'

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This calculator is designed to allow general practices to audit the levels of continuity of patient care provided in their practice. It is intended to support the RCGP Continuity of Care Toolkit and the RCGP policy on Promoting Continuity of Care in General Practice The calculator is provided as a service to general practices.

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SAPC

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The Society for Academic Primary Care (SAPC) and the Royal College of General Practitioners (RCGP) have collaborated to produce, for the first time, national guidance on the design and delivery of general practice learning and teaching in UK medical schools. The guidance is based on published evidence and current best practice in UK medical schools and has been refined through consultation with the Heads of Teachers group in SAPC, the Medical Schools Council (MSC), the General Medical Council (GMC) and the MRCGP Curriculum Development Group. It aims to support implementation of the...

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We provide a clear voice, and a strong presence, for Academic Primary Care in the complex and ever-changing Primary Care environment. We offer a point of reference and contact for those seeking academic solutions to the problems they face in the provision and study of Primary Care, and the advancement of Academic Primary Care.

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Time as a diagnostic strategy

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Abstract

The test and retest opportunity afforded by reviewing a patient over time substantially increases the total gain in certainty when making a diagnosis in low-prevalence settings (the time-efficiency principle). This approach safely and efficiently reduces the number of patients who need to be formally tested in order to make a correct diagnosis for a person. Time, in terms of observed disease trajectory, provides a vital mechanism for achieving this task. It remains the best strategy for delivering near-optimal diagnoses in low-prevalence settings and should be used to its full advantage.

Keywords: Continuity of care, diagnostic tests, patient safety, primary care, quality of care.

Introduction

Advances in medical technology have expanded the range of diagnostic tests that can be offered to patients in primary care. Indeed, the usual solutions proposed for real or perceived delayed or missed diagnoses in primary care often involve greater access to imaging, increased near-patient testing or greater access to secondary care. If establishing a diagnosis is viewed merely as a technical task, it might be assumed that performing more imaging and laboratory tests would help solve this problem. However, when used indiscriminately, such diagnostic technology may paradoxically make the process of diagnosis more costly, invasive and time consuming compared with more traditional diagnostic approaches. We, therefore, argue that the test of time offers an effective tool that should continue to be valued in 21st-century medicine.

The continued active use of the test of time in consultations needs a firm scientific basis, as emphasized by the Royal College of General Practitioners in their 2012 Commission on Medical Generalism, which called for evidence-based tools that could enhance diagnostics in low-prevalence settings. We therefore describe the scientific basis for purposefully using time as a diagnostic strategy. Many tests have high levels of sensitivity and specificity, yet in primary care, they are often found to be poor at helping to diagnose diseases with low prevalence. What may be less widely appreciated is how the test of time, the strategy of testing and retesting a patient over time, can substantially increase the total gain in certainty that a patient has a particular disease. By stating this explicitly, as a principle, its status as a key diagnostic strategy in primary care can be researched, discussed and taught.

Diagnosis in low-prevalence settings

Diagnostic 'tests' can be considered to include symptoms elicited from the patient's history and signs obtained by physical examination, in addition to laboratory tests and imaging. The low prevalence of many diseases in primary care means that even tests with an exceptionally high sensitivity and specificity have relatively high negative predictive values (NPVs) and low positive predictive values (PPVs). The high NPV of most tests helps clinicians working in low-prevalence settings, such as GPs, to correctly identify patients without disease. This is an important role because missing any major pathology can have disastrous consequences. Conversely, the low PPV of most tests, rather than any lack of knowledge or skill, means that GPs are less able to unequivocally diagnose disease. In clinical decision-making, when disease prevalence is low, although it could appear that we learn more from a negative test result than from a positive test, this is not the case; we gain little new information from a negative test result when we already know that that disease is highly unlikely.

The principal justification for performing a diagnostic test is to gain new information. Test results can have little impact on clinical decision-making when the prevalence of disease is at extremes because there is little difference between the pre- and post-test probabilities. For any test, the relationship between prevalence and predictive values is dynamic. The total gain in certainty, as indicated by the predictive summary index (PSI, ψ = NPV + PPV − 1) is greatest when the pre-test probability of the disease (prevalence) is around 50% (, ). Similarly, the number of persons needed to be examined in order to correctly predict a diagnosis of the disease (number needed to predict, NNP = 1/ψ) is also at its lowest around this midpoint (, ). Here, a positive result from a sensitive and specific test almost guarantees the diagnosis and a negative result effectively eliminates the target disorder(s) from the differential diagnosis. All tests are of their greatest diagnostic use in the 50:50 dilemma when the pre-test probability of the target disease is equally likely to be present or absent. However, in practice, the time-efficiency principle will operate most effectively at low prevalences, typically between 0% and 10% (). Here, each small increase in prevalence results in the greatest fall in NNP, i.e. tests at follow-up rapidly become more useful. This is helpful as the probable prevalence of most major pathologies presenting in primary care is <10%. The diagnostic task is to then apply more refined tests, such as imaging or specialist opinion, for patients who have reached the point of flattening on the parabola, around the 10% prevalence point. It is the particular skill of a GP working in a low-prevalence setting to safely reach this 10% zone, where definitive testing or referral becomes much more useful, by using the time-efficiency principle.

Using time in primary care

The 'test of time' involves careful initial assessment of the presenting problem(s), followed by one or more reassessment(s), ideally after a predefined period of time, although the same principles apply if the patients return entirely of their own volition. On reassessment(s), the symptoms or signs may become more clearly defined and may resolve or worsen, or new ones may appear. Diagnosis by test of time requires a sufficient understanding of the natural course of common or major conditions to enable appropriate reassessments, and this is where the GP's knowledge and experience are most clearly displayed. These conditions may have a provisional diagnosis or informal diagnostic label, e.g. 'it's probably a virus'. This enables the clinician to view the disease as an evolving process.

Explaining the time-efficiency principle

One of the most important diagnostic tasks performed by the GP is discriminating between the majority of patients with minor, usually self-limiting, illness and the minority with serious disease. For example, a cohort study of 2690 adults presenting with lower respiratory tract infections found that 92% had recovered within 3 weeks and only 1.1% were hospitalized, none of whom died. Because most patients improve within a relatively short time, this creates a dynamic process that efficiently increases the prevalence of serious disease in those patients who fail to recover in the anticipated time. The test of time thus serves as a silent adjudicator-discriminating between those with self-limiting illness and those with serious disease. It is driven by the self-limiting nature of most diseases in primary care, but it is necessary because self-limiting and progressive diseases can often not be distinguished early in their evolution. The prevalence of serious diseases increases over time to nearer the point of equipoise, where any subsequent tests will have their greatest impact on clinical decision-making.

The time-efficiency principle probably has important implications for how clinicians handle uncertainty. Schneider et al. demonstrated that the properties of the test of time were remarkable. They demonstrated that using the test of time when faced with uncertainty positively correlated with items relating to 'intuition', where a decision is reached even though the processes cannot be easily described. They suggested that the test of time contributes to a simple heuristic in keeping with Bayes theorem. Here, the clinician elicits specific points in the history and examination and then delays further testing to identify patients with a pre-test probability of the target disorders closer to the point of equipoise, e.g. in the 10% prevalence range, where any subsequent tests will be of great clinical value. Reaching this point is the reward for those clinicians willing to tolerate uncertainty and provide continuity of personal care.

When is the time-efficiency principle used?

It is important for clinicians to distinguish between patients who require rapid investigation, treatment or referral and those who would benefit from serial testing over time. The test of time should only be used in those situations where the benefit of applying time outweighs the risk of harm from a delayed or missed diagnosis, e.g. diarrhoea, where the initial assessment has not identified any substantial concerns and the usual course of presumed infectious causes is well established. By contrast, the occasional patients with red flag symptoms and signs, or who present late, warrant immediate referral.

The main diagnostic challenge in primary care is low prevalence, not opportunities to use time, which are abundant. Patients are typically seen early in the course of an illness and care should be considered continuous. By contrast, in secondary care, many patients have been through the filter of primary care, where time may have already been used. As a consequence, patients are often seen later in the course of their illness when more urgent, definitive treatment is required.

Minimizing the cascade effect

A major benefit of the test of time is that it serves to protect patients with non-serious disease from unnecessary additional testing. It is a brake upon cascade effects that occur when an initiating factor, such as an inappropriate test, is followed by a series of tests with increasing momentum, so that stopping becomes progressively harder, possibly moving to sophisticated tests and procedures where risk exceeds benefits. Cascade effects can be triggered by inappropriate data gathering such as the erroneous interpretation of a laboratory result outside normal ranges, underestimating the risks of test of treatment, underestimating the possibility of a false-positive result and the intolerance of uncertainty by the doctor. Because the chief source of error in medicine is not the quality of performance of processes but the quality of decisions to initiate those processes, it may be that the test of time serves as a relative brake against iatrogenesis. It may also be one of the key reasons why strong primary care is associated with lower health service costs.

Continuity of care

The effectiveness of the time-efficiency principle is associated with the continuity of personal care provided by the clinician. It is here that we see the value of interpersonal warmth, trust and informality, which characterize most general practice consultations, together with the careful but economical exclusion of serious illness. For patients to tolerate the inevitable uncertainty of waiting for symptoms to resolve or develop, it is vital that they are able to trust their GP. Meanwhile, great care must be taken to ensure that the social rhythms of primary care, such as appointment systems, relate to the natural course of disease. General practice should be seen as an average of 38 minutes clinician-patient contact spread over the course of a year, not just discrete, typically 10- to 15-minute isolated consultations. At any time, a GP usually has several patients due to have further tests conducted at a specified time point when the diagnosis may become more clear. For example, a borderline thyroid function test may be repeated after 3-6 months to determine whether it has become abnormal or reverted to normal. A failure to provide such continuity of care weakens the opportunity to use time as a diagnostic strategy.

Circumventing the test of time

Primary care operates in a relatively technologically unsophisticated environment remarkably well suited for the populations it serves. In many ways, the time-efficiency principle typifies this approach by using the trust that comes from strong clinician-patient relationships to allow time to be actively used for self-limiting conditions to resolve or pathology to emerge. In recent years, this has been challenged by a growing interest in near-patient diagnostic testing, particularly in the USA, where 20% of laboratory results are performed and analysed solely in primary care. In doing this, the doctor lessens the use of the time in an attempt to diagnose disease earlier in the course of an illness. Such innovations can be quickly established in practice, especially when promoted by commercial interests, so that within a short space of time, the onus is on the doubter to show that they do not work rather than on proponents to show that they do. The test of time can also be circumvented by requesting wide batches of 'routine tests' early in the diagnostic process. This can come from patient pressure or defensive practice, an attempt to minimize all uncertainty as an assumed safeguard against litigation. Perhaps the greatest irony is that this approach may not only be counterproductive, it may actually increase malpractice risk. Studdert et al. argued that the more that refined diagnostic tests with low predictive values are performed for a given condition, the more likely is this to become a legal standard of care.

Conclusion

The challenge for primary care and other low-prevalence settings is to only make diagnoses that are actually useful to patients, at the optimum time, while living with the uncertainty of informed doubt. The trust patients have for their doctor should be matched by a willingness to tolerate such uncertainty and not rush for technologically appealing investigation before time can be used appropriately to identify more clearly the possibility of serious pathology. If we cease to provide patient-centred diagnostics as reflected by the time-efficiency principle, it is primarily because we have lost our sense of respect towards the natural history and prevalence of disease that we see every day. If we allow a false reliance on inappropriate near-patient diagnostic testing, and residual alarm from rare late diagnoses where harm has ensued, to push us towards making over-refined diagnoses unnecessarily early, the costs for patients and for professional morale will be considerable.

Declaration

Funding: none.

Ethical approval: none.

Conflict of interest: none.

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The time-efficiency principle: time as the key diagnostic strategy in primary care

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The test and retest opportunity afforded by reviewing a patient over time substantially increases the total gain in certainty when making a diagnosis in low-prevalence settings (the time-efficiency principle). This approach safely and efficiently reduces the number of patients who need to be formally tested in order to make a correct diagnosis for a person.

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Onexamination

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Medical Exam Revision from BMJ OnExamination

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BMJ OnExamination online medical exam revision specialists. Medical exam question resources written by expert clinicians. Try our practice questions now!

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Passmedicine

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e-learning for healthcare

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providing e-learning to educate and train the health and social care workforce

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Divided we fail - Iona Heath

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The profession

The crucial division between GPs and specialists that we see in the UK today, and which has been recreated to a greater or lesser extent around the world, is a gift of history and appeared in Britain during the years between the Apothecaries Act of 1815 and the Medical Act of 1858. At this point, specialists took control of the newly built modern hospitals. GPs were excluded and the principle of referral from GPs to hospital specialists was established. As a result:

This gradually became translated into the distinction that we teach medical students:

In hospitals diseases stay and people come and go; in general practice people stay and diseases come and go.

In hospitals and universities, specialists began their ever more detailed elaboration of biomedical science, slowly constructing taxonomies, unravelling aetiologies and experimenting with various modalities of treatment. And all of this has brought enormous technical advances, increasingly effective treatments and, as a direct result, much relief of suffering.

Meanwhile, GPs remained close to their patients and communities and were able to observe the generation and progression of illness and disease within particular life contexts and stories. They saw disease affecting a succession of unique individuals and came to understand the extent to which individuality modulates disease so that no two individuals ever experience either illness or disease in the same way-a phenomenon that Tolstoy describes so well in War and Peace:

GPs developed a rich understanding of the inconsistent relationship between symptomatic illness and biomedical disease, between suffering and pathology. Then, whenever patients were referred to specialist colleagues, these patients would usually return to their GPs and recount their experiences of specialist and hospital care. As a result, as biomedicine made its advances, GPs became more and more aware of the power of scientific medicine for both good and harm; more aware of the dangers as well as the benefits and, as a direct result, they developed a cautious, parsimonious approach to investigation, diagnosis and referral. These instincts almost certainly contribute to explaining the findings of Barbara Starfield and her team at Johns Hopkins University that a strong system of primary care produces better health outcomes at lower cost and with less health inequity. ⁶ Such a system provides:

The division between specialists and GPs seems to have helped both to thrive in Britain, the latter to an unprecedented extent. During the second half of the 20th century the British model of GP care was adopted by many other healthcare systems. There is still substantial international interest 8,9 but it remains to be seen whether this interest, and the international prestige that it brings to Britain, can survive the current political determination to reorganise care yet again and to open it up to the predations of commercial profit. There are also worrying signs that the UK is beginning to follow the global trends that are tipping the balance of provision away from primary care and general practice towards hospitals and specialists. In 2004, for the first time ever, the number of consultant grade specialists in the NHS overtook the number of GP principals and by 2010, all GPs, including those still in training, represented only 27% of all doctors working in the NHS. ¹⁰ This matters because Barbara Starfield's findings suggest that a relative increase in the number of specialists leads to an increase in mortality. ¹¹ Why, when specialists have knowledge, skill and immense dedication, might this be so? The problem seems to have much to do with the desire to do good with the tools and interventions available, because medicine is dangerous: occasionally brilliantly effective, often helpful, sometimes disappointing and too often damaging. In his great novel Chance, Joseph Conrad describes:

Surgeons provide the easiest example. As Jack Wennberg explains:

Wennberg pays tribute to the work of J Alison Glover who, getting on for 100 years ago, drew attention to the very rapid rise in the frequency of tonsillectomy operations in the early part of the last century associated with an enormous variation in the rate of operation in different school districts:

Glover could find no explanation for this variation in terms of need and correctly attributed it to the beliefs and behaviour of different surgeons. As Starfield reminds us, none of this is benign: between 1931 and 1935, 424 school children in England and Wales died following tonsillectomy. In the context of general practice, each death represents a devastated family with repercussions lasting years. No wonder GPs are so clear about potential harms of medical intervention and have a tendency to be sceptical of received wisdom.

Good intentions continue to drive variations in the rates of intervention. The optimal level of, for example, caesarean sections, or spinal surgery for back pain or magnetic resonance imaging (MRI) scanning for headache, is very difficult to establish. However, not surprisingly, the number of specialists is directly associated with the number of interventions. ¹⁵ More specialists mean more interventions, both diagnostic ¹⁶ and therapeutic, especially in systems that reward interventions through payment for performance. More intervention implies both costs to the taxpayer and the possibility of profit but it is not necessarily a good thing. Furthermore, properly informed, shared decision making, facilitated by decision aids for patients, about accepting or rejecting major elective surgery, have demonstrated reductions in the more invasive surgical options by 25%, with no adverse effects on patient satisfaction or health outcomes. ¹⁷

Today we see the seductive possibility of preventing disease ratcheting up good intentions and the wishful thinking which too often underpins them. As Ilana Löwy says:

The evidence is now overwhelming that cancer screening causes significant harm through overdiagnosis, and the stress and sequelae of false positives. 19,20 And yet this harm is caused by good doctors striving to prevent people from succumbing to horrible diseases. Doctors and patients collude in obscuring the problems of overdiagnosis, preferring to present patients as having been 'saved' from cancer. And the whole messy situation is compounded by the fact that overdiagnosis leads directly to improved survival figures, which are much appreciated by clinicians and policymakers alike, while leaving mortality rates unchanged. ²¹ This is yet another manifestation of what the epidemiologist Alvan Feinstein described as the Will Rogers phenomenon. Will Rogers (1879-1935) was an American humorist, himself from Oklahoma, who claimed that:

When the Okies left Oklahoma and moved to California they raised the average intelligence level in both states

and so inspired a whole genre of similar jokes referring to different geographical locations. A similar phenomenon occurs whenever the range of biomedical abnormality is extended. ²² As more and more people previously considered normal are included within the definition of, for example, hypertension or diabetes, outcomes appear to improve: rates of hypertensive stroke and diabetic foot amputation appear to fall. Increasing the denominator, by extending the definitions of disease and lowering the thresholds for preventive interventions, creates the illusion of improved population outcomes while there is no

difference at all in the outcomes for affected individuals. Jack Wennberg argues the urgent need to:

The simplistic diagram shown in attempts to illustrate the importance that GPs attach to scrutinising the border between illness and disease, shown by the grey vertical bar. Stressful life experience and the symptoms of illness are in constant flux, with symptoms of headache or abdominal pain or palpitations, to give just a few of the more common examples, being just as likely to be caused by oppressive social conditions or interpersonal strife as by anything that biomedical theory would recognise as disease. The interface between illness and disease is where the huge undifferentiated burden of human distress and suffering meets the classifications of scientific medicine which have been developed with the aim of enabling humanity, to a still very limited extent, to understand and control the experience of illness. Illness is a perception of something being wrong, a sense of unease in the functioning of the body or mind; disease is a theoretical construct, a unit in the taxonomy of scientific medicine, which offers both the benefits and the risks of that endeavour. GPs see much more illness than disease but for specialists, the opposite is true. The demise of religious and philosophical explanations for the arbitrariness of human suffering has left the modern world with limited means of understanding and coping. Illness is one of the few valid outlets for human distress but if such illness is wrongly interpreted as disease all kinds of damage can be done. And all this is made much more difficult by the collective hubris of doctors which fuels ever-increasing public expectations of perfect health and consistent longevity, which are eagerly exploited by both journalists and politicians, and, most of all, by the pharmaceutical industry.

GPs have learnt from experience the benefits, to both the individual and to society, of holding the border between subjective illness and the disease categories recognised by biomedical science; of confining people within those categories only when such labelling will be positively useful to them; and of deliberately minimising exposure to the harms of medical technology. In this way, general practice attempts to direct both the power and the rising costs of biomedical science where it can help rather than where it harms. Holding the border between illness and disease underwrites the cost effectiveness of the health service to a far greater extent than gatekeeping at the point of referral, shown by the blue vertical bar. As patients move along the trajectory which begins with their own assessment of their illness symptoms, and moves on to the decision to see a GP and then, perhaps, to a referral to a specialist, the prevalence of biomedical abnormality increases at each stage and diagnostic tests work more robustly. The predictive value of any biomedical test, be it a question in a formal history, an element of the clinical examination, a blood test or a sophisticated radiological examination, is dependent on the prevalence of the given condition in the population that is tested; the higher the prevalence, as in specialist practice, the greater the predictive value; the lower the prevalence, as in general practice, the lower the predictive value. ²⁴ Biomedical science is proportionately less robust in an unselected population with low prevalence of serious disease. And one of the principal achievements of general practice is to provide very broadly based diagnostic skills which can select, through the referral process, high prevalence populations for specialist practice and thereby ensure the effectiveness of specialists. Given the low levels of prevalence with which GPs work, it is perhaps more remarkable that they get things right as often as they do, not that they sometimes get it wrong.

The trajectory of the patient, however good their medical care, will always, eventually, end in death. And here again, the experience of specialists and GPs diverges. When, last year, I despaired of the prevailing talk of an epidemic of non-communicable disease and asked what we wanted to die from and whether we would prefer to die in accidents or from infections, ²⁵ I received this very wise response from a specialist:

We, as consumers and providers of health care, know all too well about the certainty of death. We pretend and lead our lives trying to ignore this inevitability. And, it is becoming easier to do so. We concentrate on one cause of morbidity, devise dubious early diagnoses, tout treatments focusing on proxy measures and set aside competing comorbidities. We have come to believe, either sincerely or otherwise, that death from causes outside of our own dedication or specialty is

So a death from a non-cardiac cause can be regarded as a triumph for a cardiologist, but all deaths fall within the remit of the GP. Both specialists and generalists need perhaps to look more honestly at the effects of these postures of denial on those we care for and on society more generally. The UK has achieved something precious: a single but dualistic profession with common initial training, equal status and useful reserves of mutual respect. Specialists and GPs, though sometimes perceived as opposites, are inextricably dependent on each others' skills and, crucially, most are keenly aware of the extent of this interdependency. GPs can only work safely to the limits of their knowledge and skill if they can refer easily and promptly to their specialist colleagues when those limits are reached. Specialists can only use their skills maximally if they are enabled to work with a highly selected population for whom their particular skills are appropriate. There is an almost perfect complementarity between the two parts of the profession and the interface between GP and specialist care needs to be seen primarily as a means of extending the effectiveness of both.

Regrettably, the latest rounds of political manipulation of the National Health Service in England have seemed intent on substituting competition for cooperation in the relationship between specialist and generalists. Medical specialists employed by acute hospital trusts are now working within a framework of incentives which provides 'Payment by results' ²⁷ while medical generalists are being encouraged or coerced into undertaking commissioning, ²⁸ the intention of which is to keep patients away from costly hospital services. These policies are driving a wedge between specialists and generalists and making it more and more difficult for the two parts of the profession to work collaboratively in the interests of patients.

How can clinicians trapped within these ideologically imposed structures respond? Many of the early symptoms of serious disease are worryingly common in general practice. When such symptoms do not run the most probable self-limiting course, a GP can feel rapidly out of his or her depth and needs ready access to trusted specialist expertise. It is entirely to be expected that individual GPs with different ranges of experience will need to resort to different rates of referral and these rates will vary across different specialties according to the practitioner's varying level of knowledge and confidence. Any financial incentive aimed at limiting referrals is likely to prove dangerous for patients and practitioners alike. At the point of referral, serious problems can arise. The whole machinery of 'Choose and book' and referral management centres has made it increasingly difficult to refer to a named consultant. A referral should have the nature of a personal introduction mediated by trust. Instead, it has all too often become the lottery of computer dating. Health service bureaucrats seem to have little understanding of the importance of personal relationships in healthcare: between doctors with different skills and between doctor and patient. Specialists and GPs have much to learn from each other and this potential for mutual education for the benefit of all is proportionately more powerful the more it is linked to the care of particular patients. As clinicians, it is our professional and moral responsibility to build these relationships because it is increasingly clear that no one in the politics or bureaucracy of the health service is prepared to build them for us. ²⁹

The body

There are many different ways of viewing and interpreting the human body but there is a specific dualism that characterises medicine, with the body viewed both as a standardised human object, defined by biology, and as a unique human subject, created by biography. Only the doctor contains this dualism within his or her own body, combining scientific knowledge of the body as an object, with the subjective experience of living within the capabilities and constraints of a particular body. ³⁰ Biomedical science has made prodigious advances by viewing the body as a standardised object. Yet, as we have seen, although this works relatively well in some aspects of specialist practice, it works much less so in general practice. Alongside the undeniable progress, all clinicians are becoming more and more aware of the limitations of treating human individuals as interchangeable units at almost the same time as the bureaucracy of healthcare seems more and more driven by the attractions of this model and its attendant guidelines, quality indicators and payment for performance.

Science and poetry

In 1887, Anton Chekhov, who was of course not only a great writer but also a doctor, wrote in a letter:

He anticipates another almost perfect complementarity: this time, between science and art, which has the potential to translate into complementary views of the body based on biology and biography. In an essay written in the 1940s, the great francophone poet from Martinique, Aimé Césaire, argues that:

To explain further, he quotes an earlier essay by Aldous Huxley:

We all think we know what a lion is. A lion is a desert-colored animal with a mane and claws and an

And Césaire continues:

It is just the same with knowledge. Scientific knowledge is a lion without antelopes and zebras. It is gnawed from within. Gnawed by hunger, the hunger of feeling, the hunger of life.

Poetic meaning emerges from combinations of words and thought. Experience, ideas and language reinforce and change each other in a continuously evolving process described by George Steiner as 'the informing reciprocities between grammar and vision'. ³⁴

The American William Carlos Williams was both a GP and a poet and he experienced the words spoken by his patients, in the privacy of the consulting room, as the closest that many of them would come to the creation of poetry: words welling up from what is anything but a standardised bodily object, words chosen to express the deepest of feelings and fears.

Patients' presentations of their symptoms emerge rather than result from their experience of the symptoms themselves. Each individual chooses and uses words differently and gives different expression to his or her symptoms. Each patient attempts, with more or less success, the aspiration described by Wordsworth in the Twelfth Book of The prelude:

Each dyad of doctor and patient generates a different response to the particular patient's predicament. William Carlos Williams again:

The physician enjoys a wonderful opportunity actually to witness the words being born. Their actual colors and shapes are laid before him carrying their tiny burdens which he is privileged to take into his care with their unspoiled newness. He may see the difficulty with which they have been born and what they are destined to do. No one else is present but the speaker and ourselves, we have been the words' very parents. Nothing is more moving.

What our patients tell us when they find the words to speak the poem of their lives, when they struggle to give expression to some of their deepest feelings and most difficult thoughts, touches on what it is to be human. The great poets have the skill to express feelings that many others, as patients, as doctors, as human beings, will experience at some time in their lives. In this way poetic knowledge makes us feel less alone and can provide comfort, especially in situations where science can do nothing. Great poetry is grounded in the intransigence of nature and the contingency of experience and allows no room to good intentions or wishful thinking. Take a single poem by the Scottish poet Norman MacCaig:

Myself after her death
I'm exiled from what used to be my country. It welcomed me with gifts of peace and of storms, with heights of mountains and altitudes of joy. Not now.

No, says the wall, and I turn back.

No, says the mountain

And I sit sad in the valley

Listening to the river that says

Trespasser, trespasser, trespasser.

I stubbornly say, All the same

And I know that's true

But I know also

Why it fails to recognise me.

This captures all the bewildering disorientation of bereavement, yet, at the same time, reorientates the reader because as Seamus Heaney points out:

Robert Frost describes poetry as 'the shortest emotional distance between two points: the writer and the reader'. And this is often the intensity of connection that doctors need if they are to come to an appropriate diagnosis, assuming that concept is taken in its broadest sense. Scott Murray and colleagues conducted interviews with 20 people, recently diagnosed as having inoperable lung cancer. They discovered that laying the transcript out as poetry gave it an immediacy and an impact that was lacking in prose:

Now we were getting ready

To go on our holidays

And I'm losing weight,

Losing weight

I was 15 stones

And that was in two months.

And that's when I knew

With their discovery of how readily the transcripts 'fell into the rhythms and cadences of poetry', ³⁹ the researchers appear to confirm the validity of Robert Frost's assertion, William Carlos Williams' observation and Chekhov's aspiration.

Biology and biography

I have tried to show that there is more to medicine than science and that poetic knowledge is as important as scientific knowledge in the territory of human suffering. It is too easy for those who pride themselves on the hardness of their science and the robustness of their thinking to dismiss these sorts of insights as sentimental and overly emotional but the more we discover the power of biography to modulate biology, the less this position is tenable. ⁴⁰ Biography, if it is to be included in the consultation, must be elicited as narrative and the more painful and damaging the story, the harder it is to tell. Doctors have much to learn, not only from poets but also from novelists whose special province is narrative.

The American philosopher Martha Nussbaum reminds us of the features of the novel:

She describes the commitment of the novel:

to the moral relevance of following a life through all of its adventures in all of its concrete context.

And science is beginning to show that there is also a medical relevance. Lives wound bodies and wounds leave deep bodily scars that never fully heal. They are caused by trauma including terrible accidents and injuries but they are also caused by abuse, misery and humiliation, especially when these occur in early childhood. The patients we cannot cure, the ones who return again and again, have wounds and all too often we remain ignorant of their nature. In her retelling of the story of the Greek warrior Achilles, Elizabeth Cook writes:

Each wound a story. ... He learned how to spin a story from link to link, from scar to scar. These, the stories of his father's body, were his first.

She is describing the child, Achilles learning stories from the scars on Peleus' body. Our patients' scars have the potential to reveal their stories in a similar way but only if we, as doctors, look and only if we ask.

The Achilles story is about the scars of battle but many of our patients have scars which are more physiological than anatomical and so may not be readily visible but which also record stories of violence and trauma.

It is only in recent years that science has begun to document the extent to which physiology can be scarred, so that it becomes more and more clear that violence, trauma and chronic stress should be viewed as fundamental causes of disease and premature ageing. ⁴³ Biology itself is gradually extending our understanding of how experiential wounds damage bodies. Allostasis is the process by which physiological functions respond to challenge-derived from the Greek word 'allo' for variable: so, remaining stable by being variable. Allostasis seems to be mediated by multiple physiological processes, but the body's capacity for allostasis is limited and can be overloaded by continuous and excessive stress. Allostatic overload is the physiological equivalent of Peleus' battle scars: the adaptive functioning of the body loses its flexibility and becomes fixed.

It is also clear that chronic stress damages and erodes telomeres and by this means seems to precipitate premature ageing in those affected. Telomeres shorten with age in all replicating somatic cells. Thus, telomere length can serve as a biomarker of a cell's biological (versus chronological) 'age'. ⁴⁵ The association between chronic stress and shortened telomeres has been shown for the caregivers of people with Alzheimer's disease, ⁴⁶ mothers looking after chronically sick children and women exposed to intimate partner violence. ⁴⁷

Telomerase increases telomere length and low telomerase levels have been shown to be associated with smoking and significantly greater abdominal adiposity, higher resting heart rate, fasting glucose, low-density lipoprotein and total cholesterol, and total/high-density lipoprotein cholesterol ratio. ⁴⁸ Similarly, telomere length is significantly shorter in those with mood disorders, representing as much as 10 years of accelerated ageing. This provides preliminary evidence that mood disorders are associated with accelerated ageing and may suggest a plausible mechanism for much of the morbidity and mortality that is associated with these disorders. ⁴⁹

All of this research, and of course I describe only the tip of an enormous iceberg, is very exciting to GPs because it seems to explain much of the great difficulty that we face in trying improve the health status of the poor, the damaged and the traumatised patients for whom we care. It becomes absolutely clear that the established biotechnical means at our disposal must be supplemented by biographical understanding. However, the enthusiasm within medicine for perpetuating the mind-body split is proving to be a major handicap in making further progress. ⁵⁰

The evidence suggests that mind and body are totally integrated as they are within human experience. I do not sense my body as being separate from myself, and damage in either of these putatively separate arenas causes damage in the other. A truth that Laurence Sterne recorded in his own inimitable manner more than 250 years ago:

The problem, as the Norwegian GP, Anne Luis Kirkengen, puts it, is that medicine:

She finds this particularly problematic for patients suffering chronic pain which so often makes much more sense in the context of biography rather than biology. To give just one example, a history of pelvic pain or gynaecological surgery is significantly associated with reported childhood sexual abuse. ⁵⁴ When symptoms rooted in a traumatic and damaging biography are treated as biotechnical problems, medicine has an alarming tendency to cause more harm than good. Patients with chronic pain tend to be defined as somatisers and the Danish researcher, Peter Fink, has shown that those identified in this way were exposed to more frequent and more extensive surgery and other medical intervention than non-somatisers; most of the operations were abdominal or gynaecological; and three out of four operations did not have the intended effect. ⁵⁵

In 1995, Richard Horton, the editor of the Lancet, wrote a paper about the French philosopher Georges Canguilhem in the Journal of the Royal Society of Medicine. Horton noted that:

For Canguilhem, as for Kirkengen, the definition of the abnormal should be grounded in human experience not in statistically deviant biological metrics:

Adverse experiences early in childhood include physical, emotional, or sexual abuse; witnessing domestic violence; growing up with household substance abuse, mental illness, parental divorce, or an incarcerated household member. Such experiences all too often evoke feelings of life gone wrong and have been shown to predict future premature mortality, to the extent that people with six or more adverse childhood experiences died nearly 20 years earlier on average than those without any. ⁵⁸ Also such experiences appear to predict adult autoimmune disease which is consistent with recent biological studies on the impact of early life stress on subsequent inflammatory responses. ⁵⁹ In the context of a damaging childhood, the developing brain is cumulatively exposed to repeated stress responses with resulting impairment in multiple brain structures and functions. Adverse childhood experiences markedly increase the risk of smoking, alcohol and substance misuse, obesity, depression, self-harming and suicide, and multiple sexual partners. As Kirkengen puts it:

Children who, more than anything, have learned that they are worthless and not appreciated turn into young people who know neither their right to be protected nor how to protect themselves.

This seems to echo the words of the poet John Clare, written in the asylum in Northampton in about 1844:

The Adverse Childhood Experiences (ACE) Study ⁶¹ pyramid summarises the current state of understanding. Adverse child experiences lead to social, emotional and cognitive impairment, which in turn lead to the early adoption of risky health behaviours. These play out in disease, disability and social problems, and culminate in early death. Finally, there is evidence that damage can be passed on from generation to generation 62,63 to the extent that it seems possible that the grotesque trauma of slavery is still present in the relatively poorer health of descendent populations today. 64,65 However, prevalence rates for type 2 diabetes are strikingly lower for people now living in the Caribbean compared with those living in the USA or in Britain which suggests that ongoing racism and socioeconomic inequality continue to play the major role. ⁶⁶

Trauma is a breakdown of the predictability and therefore the security of the world and, in this context, it is interesting that the word 'trauma' comes from the Greek for wound with all of its connotations of bodily harm. Natural disasters like earthquakes, floods or avalanches, cause immediate injury but, beyond that, they defy our quotidian expectations, disrupt our sense of safety in the world and so cause lingering trauma. Much more commonly, human beings do terrible things to one another and in doing so have the potential to wound, scar and traumatise human bodies and undermine health at every level of functioning. Such interpersonal wounding disrupts our sense of safety much more fundamentally and is proportionately more damaging, as the philosopher Simone Weil so clearly understood:

As doctors, I think that we understand that the mind is socially constructed; now we are being challenged to see the body in the same way. The pressing question is, how should the medical profession respond?

Society

The biology of biography makes the structural violence of unjust societies of immediate relevance to doctors. The medical anthropologist Nancy Scheper-Hughes defines structural violence as:

Poverty, racism and 'other invidious distinctions' create chronic emotional stress and directly damage the functioning of bodies, leading to profound health inequalities and early death. In her extraordinary essay on The Iliad, Simone Weil writes:

Structural violence exerts just this force. When someone is turned into an object or a thing, they are no longer acknowledged as being fully human. Weil continues:

The idea of a person's being a thing is a logical contradiction. Yet what is impossible in logic becomes true in life, and the contradiction lodged within the soul tears it in shreds. This thing is constantly aspiring to be a man or a woman, and never achieving it-here, surely, is death but death strung out over a whole lifetime; here, surely, is life, but life that death conceals before abolishing.

When society and medicine combine to exert this kind of force, atrocities become almost inevitable. Medicine has an infamous history of collaboration in the demonisation and persecution of those perceived as 'other' and almost every possible dimension of otherness has been used as the pretext: indeed, I wonder whether we are now beginning to see it in relation to obesity. The great medical historian Charles Rosenberg argues that:

He proposes that, because of this, we need much greater understanding of individual experience of disease in time and place, the relation of culture to the definition of disease, and the role of the state in defining and responding to disease. To a considerable extent, the 19th-century concepts of the deserving and the undeserving poor have been replaced by those that draw very similar distinctions between the deserving and the undeserving sick. As doctors and as citizens, we need always to be terribly careful not to fall into these traps and not to contribute further to what the writer and novelist WG Sebald described as:

The socio-political construction of health inequality has become undeniable. ⁷² As society becomes ever more economically polarised, health is systematically damaged by the structural violence this entails and yet governments still appear to believe that health inequality can be tackled in isolation from the socioeconomic inequality that drives it. Doctors have seemed content to collude in this offloading of responsibility through the rhetoric of 'lifestyle medicine', ⁷³ a sophisticated variant of the age-old game of victim-blaming. Paul Farmer argues that the central contributions of medicine and public health to 'future progress in human rights will be linked to the equitable distribution of the fruits of scientific advancement'. ⁷⁴ How can we ensure that this is taken to apply to scientific advances in the biology of biography just as much as to advances in biotechnology?

How will doctors respond? For some the biology of biography cries out for a socio-political solution; for others it appears to represent a technological and economic opportunity. For me, the new understanding of the pathways between adverse experi ence and disease mean that doctors should lobby much more strenuously to protect the vulnerable and be prepared to advocate for all those on the losing side of a society divided by structural violence. The evidence suggests that society should invest much more heavily in the early years of childhood and in providing opportunities for families to thrive. The present situation should be considered completely unacceptable: society both neglects and demonises vulnerable families, ignores the continuous process of damage that is undermining the health of poor children and then blames, and again demonises, health and social care professionals when children die.

Yet, to date the vast majority of doctors have sought refuge in biotechnology. Instead of advocating approaches which would tackle the causes of the causes, medicine has tended to confine itself by intervening on the ACE pyramid at the level of risky health behaviours. At this point, intervention is likely to be relatively ineffective because the functioning of the body is already damaged. Clearly we should treat those who are sick but this should be as well as attempting to minimise violence and abuse, and promoting a much more equitable distribution of wealth, hope and opportunity within society, rather than instead. We now face a possible future which I find both disturbing and distressing. Returning to telomeres and telomerase, the brilliant research in this field ⁷⁵ should lead to improved support for those who shoulder a disproportionate burden in the care of the sick, frail and demented and in providing protection for those exposed to intimate partner violence. Instead, there seems a real possibility of a market for expensive interventions designed to increase levels of telomerase. Once again we seem prepared to ignore the detail of lived human suffering, preferring to focus on the technological fix which treats the body as a standardised object.

Petr Skrbanek argues that:

Perhaps we are simply stuck with Nabokov's observation of:

St Luke and gentleness

William Harvey determined that this Oration should take place each year on, or as close as possible to St Luke's feast day, which is today. Being constitutionally irreligious, I had no idea, until I was asked to give the Oration, that St Luke is the patron saint of physicians or that he was himself a physician. I now understand that he is also the patron saint of artists, surgeons, students and butchers which shows an interesting and perhaps instructive range.

In the first book of De Monarchia, Dante Alighieri describes St Luke as 'scriba mansuetudinis Cristi' which was translated by Aurelia Henry in 1904 ⁷⁸ as 'the writer of the gentleness of Christ'. St Luke's gospel includes six miracles and 18 parables which are not found in the other gospels. Many of these concern healing and kindness and he seems particularly concerned with the predicament of the poor and downtrodden. It is just possible that gentleness is the key to the future of medicine.

In 1979, the medical sociologist Aaron Antonovsky wrote his seminal text, Health, stress and coping, ⁷⁹ in which he proposed that it is more important to attempt to identify and support people's resources and capacity to create health than to concentrate on risks, ill health, and disease; that the focus should be on salutogenesis rather than on pathogenesis. ⁸⁰ He suggested that what he termed a 'sense of coherence' might promote salutogenesis by buffering the effects of chronic stress and so raising the threshold for allostatic overload and the consequent bodily harm. He defined the sense of coherence as:

And he criticised the traditional dichotomised view of public health which describes curative medical care as fishing people out of the river downstream while preventative healthcare seeks to stop them falling in upstream. Antonovsky argued that health and sickness are not the opposites that this model would suggest and that:

To remain with the metaphor: we are all, always, in the dangerous river of life. The twin question is: How dangerous is our river? How well can we swim?

His thesis is that however dangerous the river, a sense of coherence helps people to swim.

It seems clear that Antonovsky's coherence is linked to John Bowlby's theory of attachment. Secure attachment to a principal caregiver in early infancy provides the foundation for a lifelong sense of coherence and a belief that it is possible to make sense of the world and to find meaning in one's place within it. On the other hand, disordered patterns of attachment precipitated by destructive or damaging parenting patterns make the world seem unsafe from the outset and it will be proportionately more difficult to find meaning, security and coherence. Those with such experiences will be beginning to move up the adverse child experience pyramid towards poor health and early death. Yet people who have been traumatised and who struggle to recover are frequently marginalised within healthcare systems, especially if the source of their trauma also causes shame and so is profoundly difficult to disclose. Dignity, respect or even interest are too often in short supply.

The clear implication is that physicians should play a much greater role in helping patients to cope with the challenge and stress of illness, by helping to make it more comprehensible, manageable and meaningful. Kirsti Malterud and Hanne Hollnagel have shown how the use of key questions can help patients to identify and articulate their personal salutogenic resources 83,84 and to provide clues as to the nature of the diagnosis in both biotechnical and biographical terms. ⁸⁵

Relationships help to create meaning and are fundamental to human existence. Human beings seek to build enduring and trusting relationships in all spheres of life, and these qualities in the relationship between patient and doctor will be proportionately more important for those whose lives have been irreversibly marked by abusive and destructive relationships. One of the key roles of the doctor is to work with patients to find an explanation of what is happening to them. A coherent explanation that can be understood and given meaning by the particular patient within the individual context of their own life story helps them to feel less afraid and more hopeful. This optimism seems to actively promote recovery. Physiological processes, meanings and relationships are all interconnected and the interactions between patients and those who care for them can either diminish or exacerbate symptoms and suffering. ⁸⁶ Meaning has biological consequences ⁸⁷ and can both harm and heal. ⁸⁸

Harm becomes imprinted on the body through neuroplasticity but this is not a one-way process and the brain's capacity for adaptation can also be a means of making people better. Each of us constructs a more or less coherent autobiographical narrative which is constantly reviewed and refined. It is through narrative that we make sense of what is happening to us and begin to make sense of the world. The freedom and the delight is that narratives can be changed and doctors, by listening and by investing the experience and perspectives of patients with respect and dignity, can help to shift narratives which have become damaging and stuck. A story of failure and suffering can be recast as one of courage and endurance in the face of impossible odds; one of inability to cope at work can become one of exploitation and seeking solutions in forming alliances and activism.

The suppleness of narrative contrasts strongly with the fixed nature of much biomedical labelling. The longer I work in general practice, the more sceptical I become about the labels and diagnostic categories that we use all the time. Individual patients with diabetes or asthma, multiple sclerosis or cancer, are so different from one another and seem to experience their diseases so differently that I have sometimes wondered about the usefulness of the label. And this seems even more true of labels such as depression, schizophrenia or personality disorder. Commenting on a short story by Anton Chekhov, a GP from Finland, Raimo Puustinen, noted that:

It is not surprising that patients should adopt our labels and our vocabulary but it is one of the ways in which their stories become constrained.

We give people a label to put them in a group so we can learn more about the disease or condition that they have in common and, to this extent, the generalisation is constructive, but it is also destructive. The doctor, while actively using the generalisations of biomedical science, has a constant responsibility to refocus on the individual, the detail of their story and the meaning they attach to it: drawing on Simone Weil's conception of 'creative attention'. ⁹¹

Vladimir Nabokov asserts that:

And in his strange story Tlön, Uqbar, Orbis Tertius, Jorge Luis Borges suggests that nouns are about space and verbs about time ⁹³ which implies that a single word will never do. Yet in medicine, much of the time, we try to make sense of the world with single words, albeit long ones. However, if we accept Borges, we must arrive at the conclusion that medical diagnoses are only about space and not about time, which is interesting, particularly as we try to link diagnosis to prognosis in a dangerously fatalistic way. Words used in diagnosis, as a kind of biomedical revelation, are fixed in time; words used in narrative, as a revelation of the human condition, stretch across time.

We need to work very hard to prevent our patients and ourselves becoming trapped within the words and the language that we use or that surrounds us. In an essay written in 1974, Primo Levi warned:

Nowadays we teach communication and consultation skills to medical students and young doctors. My worry is that we are teaching these as techniques to be used instrumentally, making the relationship between doctor and patients a means to an end rather than an end in itself. George Steiner, in his book on Heidegger, writes:

The vital relation of otherness is not, as for Cartesian and positivist rationalism, one of 'grasping' and pragmatic use. It is a relation of audition .... It is, or ought to be, a relation of extreme responsibility, custodianship, answerability to and for. ⁹⁶

Finding meaning and a sense of coherence in the face of illness, suffering and loss can only occur within an ongoing relationship between two human subjects and if we are genuinely to be of use, we perhaps need to test ourselves against these standards of responsibility, custodianship, and answerability to and for. And perhaps also against St Luke's standard of gentleness. Like Synge's Ireland, medicine will never be a pure and simple place but its constant interplay of opposites makes space for courage, joy, creativity and freedom and the possibility of making the world a better place. However, if beyond this, we cannot bring these opposites together into a more coherent, and in the case of society a fairer, whole, we will remain divided and we will fail.

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The crucial division between GPs and specialists that we see in the UK today, and which has been recreated to a greater or lesser extent around the world, is a gift of history and appeared in Britain during the years between the Apothecaries Act of 1815 and the Medical Act of 1858.

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Manchester triage

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NICE Talks is the podcast from UK's National Institute of Health and Care Excellence (NICE). Our podcast brings the stories behind our NICE's work to improve outcomes for people using the NH...

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RCGP e-learning

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Skip Intended for UK Health Care Professionals Only

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The RCGP eLearning podcast gives you the opportunity to further deepen your learning via a different medium: whether you listen during your commute, on a road trip or doing the dishes, the opportunity to gain more insight into a topic is always there. Each episode is hosted by an RCGP clinician who is joined by a clinical expert sharing their specialist knowledge on a featured topic. You can of course claim CPD points for each episode that you listen to, based on its duration and the time spent on reflection or implementation into your practice.

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Skip Intended for UK Health Care Professionals Only The RCGP eLearning podcast gives you the opportunity to further deepen your learning via a different medium: whether you listen during your commute, on a road trip or doing the dishes, the opportunity to gain more insight into a topic is always there.

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e-GPlearning

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Join DrGandalf and the team from X-on as they show you the latest updates in telephony for your practice. Links and timestamps below in the description

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Join Andy and Gandhi as they explore the developing aspect of online consultations and how they fit in current General Practice and try to answer the question of 'are GP online consultations sustainable'?

Remote consultations 5-day challenge: https://egplearning.podia.com/remote-...
Have you considered a standing desk? See how I have used one for over four years and learn all you need to know about standing desks for doctors. 00:00 Intro and On Your Feet Britain 02:08 Pros of standing desks 03:45 Cons of standing desks 05:00 Types of standing desks 05:10 Full standing desk 05:56 Standing desk riser 06:55 Stationary desk riser 07:47 Desk riser demo 08:32 What do patients think? 09:28 Standing desks or activity stations? ⭐Star posts⭐: 👨🏾‍⚕️Dr Gandalf's Top medical equipment for General practice 👨🏾‍⚕️ see here: Subscribe to or follow the eGPlearning platform for more videos, app reviews and content to support technology-enhanced primary care and learning. Other networks:
Are you ready for the next TPP SystmOne update- a massive one showing a full guide on the communications annexe and how to use it in practice, with new functionality to help with your workload in practice

Join with your chance to ask questions and more.

For the video on how to add your signature to a med3 see here: https://youtu.be/mRzrV9syBv8

Join S1 FBUG Facebook group: https://www.facebook.com/groups/s1fbug

We discuss what medical technologies will make an impact in 2021. Explore how to use the Hype Cycle to understand the journey new technologies go through as they are adopted. This concept can help you time investment in new technologies for your organisation or as an individual.

What is the GPC and other organisations that support General Practice?

Find out in this complete guide with Dr Katie Bramall-Stainer as she explains the history of General Practice, the GPC, BMA, LMC, and more.

This must-listen episode is a guide for anyone who wants to know what they don't teach you in GP training about General Practice.

Join DrGandalf and the team from MJOG as they share their a LIVE update on Desktop GP and how it might help your practice with the ability to ask questions.

See more at https://www.mjog.com/desktop-gp

We explore the various options open to patients and doctors when choosing smartphone apps to help people take their medication on time and as prescribed.

Join Andy and Gandhi for their regular LIVE update on all things GP and also answering the perennial question: Should you be a member of the RCGP?

Joined by RCGP President Prof Amanda Howe as they take your questions and help navigate the answers.
Here are the resources talked about in this live webinar including access to the slides. Some of these include affiliate links (if you use them I get a small affiliate at no extra cost to you). ⭐Star posts⭐: 👨🏾‍⚕️Dr Gandalf's Top medical equipment for General practice 👨🏾‍⚕️ see here: Subscribe to or follow the eGPlearning platform for more videos, app reviews and content to support technology-enhanced primary care and learning. Other networks:
Video interviews are here to stay! We discuss tips and tools to help coordinate video interviews and score candidates effectively even when the interview panel are also remote from each other.

Join a LIVE webinar with Dr Surina Chibber, co-founder of My Locum Manager. What we will share: Significant funding has been announced by NHS England to support Primary Care Networks (PCNs) and Practices to increase clinical capacity by establishing flexible digital staff banks.

My Locum Manager, in partnership with EMIS Health, has a unique solution to support flexible staffing across systems and places. Primary care is about relationships, therefore to truly address workforce capacity issues a staff bank needs to provide more than just shift booking. For a sustainable solution, flexible working should make it easier to not only access available staff but also to optimise local relationships and incentivise retention while providing new ways of working. We will share how you can easily build an engaged workforce community, increase the quality of care patients receive, deliver services at pace and seamlessly connect existing IT systems to automate your systems.

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Join DrGandalf and the team from X-on as they show you the latest updates in telephony for your practice. Links and timestamps below in the description Contact X-On: https://www.x-on.co.uk/ 00:00 Introduction 12:00 Quebusting 40:40 Q&A Join Andy and Gandhi as they explore the developing aspect of online consultations and how they fit in current General Practice and try to answer the question of 'are GP online consultations sustainable'?

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WISE GP

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Introducing the WiseGP podcast. Hosted by Johanna Reilly, WiseGP intern, these are a series of conversations about scholarship, research and the wider context of primary care. Available to download and listen on our website and on your favourite podcast provider - search WiseGP.

Please do get in touch with your feedback and let us know what you find interesting and what less so.

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Introducing the WiseGP podcast. Hosted by Johanna Reilly, WiseGP intern, these are a series of conversations about scholarship, research and the wider context of primary care. Available to download and listen on our website and on your favourite podcast provider - search WiseGP.

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GP on the move

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"gp on the move" "medical audiobook" "csa on the move" "general practice" rcgp csa akt emis workflow productivity medicine "michael poplawski" "dr michael po...

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Welcome to GP On The Move. I'm Mike, an NHS General Practitioner in Greater Manchester UK, and this channel is all about medicine, productivity and creating efficiency in GP land. "GP on the Move" is also an audiobook that comprises clinical management guidelines to 30 common GP scenarios with additional extra tips to help in everyday General Practice.

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St Helens CCG

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e-GP learning

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"digital primary care" healthtech primarycare generalpractice doctor gp "general practitioner" medicine healthapps

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The UK's leading primary care focused health technology YouTube channel and podcast, which aims to drive technology enhanced primary care and learning.

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RCGP

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The RCGP is the professional membership body for family doctors in the UK and overseas. We are committed to improving patient care, clinical standards and GP training. We provide useful information about joining general practice and GP training, we offer resources for GPs in practice, such as Revalidation and CPD and provide regular updates from across the UK.

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GP notebook

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The RCGP is the professional membership body for family doctors in the UK and overseas. We are committed to improving patient care, clinical standards and GP training. We provide useful information about joining general practice and GP training, we offer resources for GPs in practice, such as Revalidation and CPD and provide regular updates from across the UK.

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RCA marking sheet

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The UK MEC helps clinicians decide what contraceptives they can safely recommend based on the medical conditions of patients in their care. Funded by the FSRH and developed over the last 18 months by our Clinical Effectiveness Unit, this key guidance is informed by robust and up-to-date evidence on when contraceptives can and cannot be safely used.

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Red Whale

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The UK MEC helps clinicians decide what contraceptives they can safely recommend based on the medical conditions of patients in their care. Funded by the FSRH and developed over the last 18 months by our Clinical Effectiveness Unit, this key guidance is informed by robust and up-to-date evidence on when contraceptives can and cannot be safely used.

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Dermnet

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DermNet is the world's free resource and authority on all things skin. We help thousands of people make informed, evidence-based decisions on how to care for skin conditions, by providing reliable information at the click of a button.
Supported by and contributed to by New Zealand Dermatologists on behalf of the New Zealand Dermatological Society Incorporated.

Slider: Childhood infections

Guidelines for authors

Are you interested in writing for us? DermNet New Zealand is always looking for potential authors to write on new topics or to update existing ones. Potential authors interested in writing a new page are generally asked to write a topic page about a disease or condition, or a treatment, product or procedure.

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DermNet NZ - All about the skin | DermNet NZ

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Supported by and contributed to by New Zealand Dermatologists on behalf of the New Zealand Dermatological Society Incorporated. Slider: Childhood infections Are you interested in writing for us? DermNet New Zealand is always looking for potential authors to write on new topics or to update existing ones.

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The NNT

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We are a group of physicians that have developed a framework and rating system to evaluate therapies based on their patient-important benefits and harms as well as a system to evaluate diagnostics by patient sign, symptom, lab test or study.

We only use the highest quality, evidence-based studies (frequently, but not always Cochrane Reviews), and we accept no outside funding or advertisements.

© The NNT Group, 2010 - 2021

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We are a group of physicians that have developed a framework and rating system to evaluate therapies based on their patient-important benefits and harms as well as a system to evaluate diagnostics by patient sign, symptom, lab test or study.

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NB Medical

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GP CPD Courses & Training by NB Medical Education | NB Medical

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NB Medical is the UK's leading provider of CPD for GPs and healthcare professionals. View the latest CPD courses and training online today.

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CHiP study running in St Helens

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May 16, 2019

Rising health care costs are prompting fundamental changes in health care delivery and generating innovative approaches to combining teamwork, culture, and technology into systems that work for patients and physicians alike. HMS Center for Primary Care Director Russell Phillips and some current students discuss the transformation underway that can lead to improved care and better health outcomes for patients in the future.

Speakers:

Russell Phillips, MD
Director, Center for Primary Care
William Applebaum Professor of Medicine
Professor of Global Health and Social Medicine
Harvard Medical School

Megan Townsend
MD/MPP Student
Class of 2019
Harvard Medical School/Harvard Kennedy School

Mark Herzog
MD/MPP Student
Class of 2020
Harvard Medical School/Harvard Kennedy School

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May 16, 2019 Rising health care costs are prompting fundamental changes in health care delivery and generating innovative approaches to combining teamwork, culture, and technology into systems that work for patients and physicians alike. HMS Center for Primary Care Director Russell Phillips and some current students discuss the transformation underway that can lead to improved care and better health outcomes for patients in the future.

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The Vasco da Gama Movement is the Network for Young and Future Family Doctors of the European Regional Branch of the World Organization of Family Doctors (WONCA Europe). Young and Future Family Doctors are defined as those in training for Family Medicine and in the first five years after qualification as a family physician. Our activities include Events, Exchanges, Awards&Bursaries, Special Interest Groups and maintaining valuable external Relationships with other Networks. Read more About Us.

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The Vasco da Gama Movement: For Young & Future Family Doctors

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The Vasco da Gama Movement is the Network for Young and Future Family Doctors of the European Regional Branch of the World Organization of Family Doctors (WONCA Europe). Young and Future Family Doctors are defined as those in training for Family Medicine and in the first five years after qualification as a family physician.

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WONCA is the World Organization of Family Doctors, with 118 Member Organizations representing over 500,000 family doctors in over 130 countries and territories around the world, and working in partnership with the World Health Organisation.

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AAFP Home | American Academy of Family Physicians

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American Academy of Family Physicians (AAFP) represent more than 246,600 family physicians, family medicine residents, and medical students, providing outstanding advocacy, practice enhancement, education, and health of the public resources.

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EGPRN

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EGPRN is an organization of general practitioners and other health professionals involved in research in primary care and family medicine.

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Primary health care (PHC) is essential health care based on methods and technology made universally accessible to individuals, families and communities through their active participation and at an affordable cost. PHC is an integral part of a country's health system and, ideally, its main focus. It is the first level of contact for individuals, families and communities and enables health care to be delivered as close as possible to where people live and work. PHC is therefore the first element of the care continuum.

2018 marks the 40th anniversary of the Alma Ata Declaration on PHC. Countries will gather to reaffirm the PHC principles and recommit to the importance of PHC for the 21st century.

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Primary health care in the Western Pacific

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Primary health care (PHC) is essential health care based on methods and technology made universally accessible to individuals, families and communities through their active participation and at an affordable cost. PHC is an integral part of a country's health system and, ideally, its main focus.

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Welcome!

This page is used to test the proper operation of the Apache Web server after it has been installed on this server, with the InterWorx Web Hosting Control Panel. If you can read this page, it means that the Apache Web server installed on this server and is working properly.

If you are the server administrator

Login to InterWorx-CP by navigating to the NodeWorx Login Page. If that does not work, try https and port 2443.

You'll want to bookmark that login page so you can easily find it again. You can also reach NodeWorx by appending /nodeworx to the end of any domain hosted on the server or any IP mapped to the server.

Once you are logged into NodeWorx you will be able to manage all aspects of your server. Your login information should have been provided to you by the InterWorx Reseller Partner you purchased your license from or the InterWorx-CP team itself if you purchased InterWorx-CP from the InterWorx website.

ABOUT INTERWORX

InterWorx-CP is a dedicated server hosting control panel. It is useful for anyone in charge of managing or maintaining a server. It can be used to setup web hosting accounts and provide website level access to webmasters. InterWorx-CP will also perform much of the routine maintenance needed to keep a server running smoothly.

For more information regarding InterWorx-CP or any of the InterWorx line of tools please visit http://www.interworx.com.

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Test Page for the Apache HTTP Server & InterWorx-CP

# data[].attributes.attachment_link.description
This page is used to test the proper operation of the Apache Web server after it has been installed on this server, with the InterWorx Web Hosting Control Panel. If you can read this page, it means that the Apache Web server installed on this server and is working properly.

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Primary care cardiovascular society

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Welcome!

This page is used to test the proper operation of the Apache Web server after it has been installed on this server, with the InterWorx Web Hosting Control Panel. If you can read this page, it means that the Apache Web server installed on this server and is working properly.

If you are the server administrator

Login to InterWorx-CP by navigating to the NodeWorx Login Page. If that does not work, try https and port 2443.

You'll want to bookmark that login page so you can easily find it again. You can also reach NodeWorx by appending /nodeworx to the end of any domain hosted on the server or any IP mapped to the server.

Once you are logged into NodeWorx you will be able to manage all aspects of your server. Your login information should have been provided to you by the InterWorx Reseller Partner you purchased your license from or the InterWorx-CP team itself if you purchased InterWorx-CP from the InterWorx website.

ABOUT INTERWORX

InterWorx-CP is a dedicated server hosting control panel. It is useful for anyone in charge of managing or maintaining a server. It can be used to setup web hosting accounts and provide website level access to webmasters. InterWorx-CP will also perform much of the routine maintenance needed to keep a server running smoothly.

For more information regarding InterWorx-CP or any of the InterWorx line of tools please visit http://www.interworx.com.

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Test Page for the Apache HTTP Server & InterWorx-CP

# data[].attributes.attachment_link.description
This page is used to test the proper operation of the Apache Web server after it has been installed on this server, with the InterWorx Web Hosting Control Panel. If you can read this page, it means that the Apache Web server installed on this server and is working properly.

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‎Primary Care Knowledge Boost on Apple Podcasts

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A community dedicated to reducing healthcare bias in skin of color.

take the pledge

IMPACT = Improving Medicine's Power to Address Care and Treatment

Our Mission

Project IMPACT is a global effort brought to you by VisualDx to reduce disparities in medicine and highlight the tools we use to bridge gaps of knowledge and improve care.

Our Values

1. We believe healthcare providers who evaluate and treat dermatologic conditions should be able to recognize disease in all skin colors.

2. We believe technology that brings images and information to the point of care can reduce biases in medicine by bridging knowledge gaps.

3. We believe it is imperative to address healthcare disparities and to work towards health equity for all citizens of the world.

Together We Can Make an IMPACT

Health disparities continue to profoundly afflict people of color nationally and globally and the statistics are staggering. Project IMPACT was created to help reduce those disparities and help bring health equity to all people.

Disease Presentation in Different Skin Colors

Recognizing how diseases present on all skin types is key in reducing diagnostic error and improving patient care. Unfortunately, many professional resources often do not adequately provide medical education on diseases in skin of color. VisualDx has been committed to reducing bias in medical knowledge for 20 years. A recent JAAD study showed that "VisualDx demonstrates pathology on dark skin in remarkably high proportion to other resources." ⁴

Contribute Your Images

People with darker skin face worse health outcomes than their peers with lighter skin. By ensuring that clinicians and students have access to a diverse set of clinical images we can begin to improve healthcare outcomes-particularly for patients of color. Join the movement and contribute your medical photos to VisualDx.

Contribute Images

Our Global Impact

People worldwide are pledging to reduce racial bias in healthcare.

Explore the map above to see where people are pledging.

Project IMPACT and its collaborators remain committed to reducing bias and disparities in medical knowledge by improving diagnosis in skin of color around the globe.

Efforts are underway to enhance access to technology and medical resources in remote areas.

take the pledge

Digital Resources

VisualDx is an award-winning application designed to enhance diagnostic accuracy, aid therapeutic decisions, and improve patient safety. Features include the world's best medical image library to make timely clinical decisions. See the video on how to use our Skin of Color feature.

Contact us to see how other educational programs are using VisualDx to supplement their diversity, equity, and inclusion efforts.

CONTACT LEARN MORE

Aysa

A mobile app by VisualDx that uses artificial intelligence to give personalized guidance for your skin based on your photo submission.

Skinsight

Patient website by VisualDx dedicated to providing medical information on conditions affecting skin, nails, and hair.

Skin of Color Society

Articles and videos to educate on skin diseases that impact people of color.

Educational Partner Resources & Events

NMA Annual Convention

July 30-Aug. 3, 2022 | Atlanta

The National Medical Association (NMA)'s Annual Convention and Scientific Assembly is acclaimed as the nation's foremost forum on medical science and African American health. Each year, African American physicians and other health professionals from across the country convene to participate in the scholarly exchange of medical advances, discuss health policy priorities, and to share experiences. Through NMA's 26 Scientific Specialty Sections, the Convention attracts the broadest spectrum of African American physicians, academicians and scientists in the country.
Learn More

SNMA: National Post-Baccalaureate Initiative

Every 1st and 3rd Wednesday | Virtual

The MAPS Post-Bacc Initiative will host bi-monthly meetings that will have various speakers and activities to prepare you for medical school.
Learn More

Previous Next

Spotlight Series

A deeper dive on industry leaders who are making an impact, the skin conditions that affect people of color, the latest health equity research, and more.

Join the Project IMPACT Community

Improving health equity is a goal that will take a collaborative and dedicated effort. There are many ways to be part of #ProjectIMPACT and help make a difference. Join us and feel free to share your ideas, feedback, and how you'd like to get involved.

Get Involved Follow on Instagram

Take the Pledge

"I'm taking the #ProjectIMPACT pledge because I am committed to reducing bias and improving dermatologic care for people of color. https://projectimpact.org"

Share the message about #ProjectIMPACT on social media:

Share on Instagram

Share on Facebook, Twitter, or LinkedIn

From the community:

"I pledge to promote health equity and increase the 3% in #dermatology by supporting the pipeline of talented and passionate UIM students with #mentorship. As been done by @SusanTaylorMD @HarrisTryonLab @hairwithdrmare @CorySimpsonMD and countless others #ProjectIMPACT."

- University of Rochester physician

"I take the #ProjectIMPACT pledge because improving healthcare outcomes for skin of color patients is a privilege and a duty. As medical students/residents/physicians, the humblest part of our work is being servants for the under-served human beings in our communities."

- The University of Texas Health Science Center at Houston medical student

1. 2019 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; December 2020. AHRQ Pub. No. 20(21)-0045-EF.

2. Nelson B. How dermatology is failing melanoma patients with skin of color: Unanswered questions on risk and eye-opening disparities in outcomes are weighing heavily on melanoma patients with darker skin. In this article, part 1 of a 2-part series, we explore the deadly consequences of racism and inequality in cancer care. Cancer Cytopathol. 2020 Jan;128(1):7-8. doi: 10.1002/cncy.22229. PMID: 31905269.

3. White S, Ojugbele O. Addressing racial disparities in medical education: Commentary on the Curriculum Inventory Report: Coverage of racial disparity in medicine education content in accredited U.S. medical schools, academic year 2017-2018. Curriculum in Context. 2019:6(2):1-6.

4. Alvarado SM, Feng H. Representation of dark skin images of common dermatologic conditions in educational resources: a cross-sectional analysis. J Am Acad Dermatol. 2020 Jun 18:S0190-9622(20)31138-5. doi: 10.1016/j.jaad.2020.06.041. Epub ahead of print. PMID: 32565205.

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A community dedicated to reducing healthcare bias in skin of color. take the pledge IMPACT = Improving Medicine's Power to Address Care and Treatment Our Mission Project IMPACT is a global effort brought to you by VisualDx to reduce disparities in medicine and highlight the tools we use to bridge gaps of knowledge and improve care.

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Mind the Gap: a handbook of clinical signs on black and brown skin

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Mind the gap - clinical signs in black and brown skin

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Mind the gap - clinical signs in black and brown skin

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Published: 18 June 2020

Second year medic, Malone Mukwende, has been working with Senior Lecturer in Diversity and Medical Education, Margot Turner, and Clinical Lecturer in Clinical Skills, Peter Tamony, as part of a student-staff partnership project looking at clinical teaching on black and brown skins. Malone highlighted that, as a black student, he felt alienated with the way clinical skills is currently being taught due to the lack of discussion around clinical signs on darker skin.

It was agreed that this was a very important issue and an essential part of decolonizing the curriculum. The trio have designed a booklet, which will be available shortly, to raise awareness of how symptoms and signs can present differently on darker skin as well as highlighting the different language that needs to be used in descriptors.

Malone explains, "The aim of this booklet is to educate students and essential allied health care professionals on the importance of recognising that certain clinical signs do not present the same on darker skin. This is something which is not commonly practiced in medical textbooks as there is a 'white skin bias'. It is important that we as future healthcare professionals are aware of these differences so that we don't compromise our care for certain groups.

"The booklet addresses many issues that have been further exacerbated during the Covid-19 pandemic, such as families being asked if potential Covid patients are 'pale' or if their lips 'turned blue'. These are not useful descriptors for a black patient and, as a result, their care is compromised from the first point of contact. It is essential we begin to educate others so they are aware of such differences and the power of the clinical language we currently use. We will be hosting a training session for clinical skills peer tutors which will take place in July 2020.

"Multiple conversations are now taking place around what can be done to tackle health disparities in the UK and we would love for St George's to be a part of that growing conversation. Recently there was a petition calling for teaching clinical skills on black and brown skins that now has over 125,000 signatures. The petition, Covid-19 pandemic and the Black Lives Matter movement all illustrate there is an urgent need for change."

Mind the Gap is not currently published and so is not available to distribute however discussions with potential publishers are ongoing.

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Mind the Gap: a handbook of clinical signs on black and brown skin

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Published: 18 June 2020 Second year medic, Malone Mukwende, has been working with Senior Lecturer in Diversity and Medical Education, Margot Turner, and Clinical Lecturer in Clinical Skills, Peter Tamony, as part of a student-staff partnership project looking at clinical teaching on black and brown skins.

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Dorky Docs : Free Online Medical Revision

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Dorky Docs - statistics revision

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Dorky Docs : Free Online Medical Revision

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Our guides are designed to support healthcare professionals with competency frameworks, guidance and best practice to care for people living with cancer.

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I-medics

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FREE Medical Exam Question Banks ✔️ UK Doctor Exams ✔️ How to become a Doctor ✔️ Medical Jobs ✔️ 4.9 Star Google Review Rating

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Welcome to the Primary Care Rheumatology and Musculoskeletal Medicine Society - PCRMM

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Primary care rheumatology and MSK society

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Welcome to the Primary Care Rheumatology and Musculoskeletal Medicine Society - PCRMM

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The PCRMM welcomes all doctors and all allied health professionals of all grades, including trainees, who are involved in the care of patients with rheumatological and musculoskeletal conditions in primary […]

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Psychiatrienet is een website van De Tijdstroom

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ORCHA App Library

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Technology is revolutionising health and care services, but professionals require tools to find quality assured digital solutions. As the world's leading, independent digital health evaluation and distribution organisation, ORCHA enables safe digital adoption.

The Chartered Society of Physiotherapy Moves to Digital

Developing a bespoke App Library with ORCHA, the CSP enables its 59,000 members to incorporate digital technology safely in their practice. Learn how apps are now part of assessment, treatment compliance, monitoring symptoms, and allowing people to self-manage.

DIGITAL HEALTH. UNLOCKED.

Since 2015, ORCHA has been helping the NHS to find and successfully integrate trusted health and care apps into care pathways.

Our team of clinical and digital experts continually monitor and ask questions about digital health developments, providing impartial and up-to-date insights which can be accessed in our reports, brochures and opinion pieces.

For full details about how ORCHA will handle the personal information you provide to us when you sign up to our newsletter, please see our Privacy Policy.

Your Health and Care App Library

Search ORCHA's App Library, featuring thousands of independent app reviews across a broad spectrum of health conditions. Every app is evaluated against more than 350 measures across Clinical/Professional Assurance, Data & Privacy, and Usability & Accessibility, making it easy for you to find the best apps for your needs.

By submitting this form, you are providing your personal information to ORCHA, which we will use in accordance with our Privacy Policy.

For full details about how ORCHA will handle the personal information you provide to us when you sign up to our newsletter, please see our Privacy Policy.

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Technology is revolutionising health and care services, but professionals require tools to find quality assured digital solutions. As the world's leading, independent digital health evaluation and distribution organisation, ORCHA enables safe digital adoption. The Chartered Society of Physiotherapy Moves to Digital Developing a bespoke App Library with ORCHA, the CSP enables its 59,000 members to incorporate digital technology safely in their practice.

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RCGP patient safety toolkit

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Purpose

The identification and reduction of avoidable harm is a major priority for the NHS. There has been widespread attention to this issue in secondary care. Now primary care is increasingly coming under the spotlight. With funding from the NIHR School for Primary Care Research a team of researchers has developed a Patient Safety Toolkit for general practice. This developmental work involved experts from Nottingham, Manchester, Keele, Southampton, Birmingham, Oxford, Exeter and Bristol, with user and public involvement throughout the project.

With funding from the NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, and developed in partnership with the Clinical Innovation and Research Centre, the toolkit is now available on the RCGP website. General practices can use the various tools to identify a wide range of patient safety issues and make improvements to help prevent patients from being harmed.

Acknowledgements

We would like to thank the following people for their contribution to this project:

Project Steering Group

University of Nottingham (Professor Tony Avery, Kate Marsden, Dr Rachel Spencer, Dr Brian Bell, Dr Sarah Rodgers)

University of Manchester (Professor Stephen Campbell, Professor Aneez Esmail, Dr Katherine Perryman, Dr David Reeves)

University of Birmingham (Professor Paramjit Gill, Professor Shiela Greenfield, Dr Ian Litchfield, Dr Lucy Doos)

University of Exeter (Professor Jose Valderas)

University of Keele (Professor Umesh Kadam, Dr Mark Porcheret)

University of Southampton (Jane Barnett, Professor Michael Moore, Professor Paul Little)

University of Oxford (Dr Ignacio Riccabello, Dr Jeffrey Aronson, Dr Daniel Lasserson)

University of Durham (Dr Sarah Slight)

University of Edinburgh (Professor Aziz Sheikh)

University of Bristol (Professor Sarah Purdy)

GP (Dr Manny Samra)

PPI representative (Antony Chuter)

International Experts Group

Professor Mike Pringle, President of the RCGP

Professor Bruce Guthrie, University of Dundee, Scotland

Dr Neil Houston, Clinical Lead for the Scottish Safety Improvement in Primary Care Collaborative

Professor Tom Fahey, Royal College of Surgeons in Ireland

Paul Bowie, Programme Director (Safety & Improvement) at NHS Education for Scotland

Itziar Larizgoitia, Research Lead, Patient Safety Programme, WHO

Sathya Naidoo, Associate Postgraduate Dean , Health Education East Midlands

Gordon Schiff, Associate Director at Center for Patient Safety Research and Practice, Brigham & Women's Hospital, Boston, USA

Jurate Svarcaite, Head of Pharmaceutical Care Department at UAB Nemuno vaistine, Lithuania

Andreas Soennichsen, Chair of General Medicine and Family Medicine at the University of Witten / Herdecke, Germany

Michel Wensing Professor of Implementation Science, Institute for Quality of Healthcare, Radboud University, Nederlands

This toolkit was developed as part of the Patient Safety Spotlight Project, which was a one year collaboration between the NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre and the RCGP from 2015-16. This report reviews the project's impact and legacy.

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The identification and reduction of avoidable harm is a major priority for the NHS. There has been widespread attention to this issue in secondary care. Now primary care is increasingly coming under the spotlight. With funding from the NIHR School for Primary Care Research a team of researchers has developed a Patient Safety Toolkit for general practice.

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Explore epidemiologic data from FaMe-Net

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GPnotebook helps busy GPs save time by providing easy access to reliable, concise information to support quicker, more assured clinical decision-making.

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Switching Antidepressants

To see the consequences of a switch between antidepressants click in the crosstable below:
the switch is made "from" (vertical) "to" (horizontal). First read the general considerations concerning switching antidepressants

If you any have suggestions, please send them to info@tijdstroom.nl. We are looking forward to your feedback.

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Switching Antidepressants To see the consequences of a switch between antidepressants click in the crosstable below: the switch is made "from" (vertical) "to" (horizontal). First read the general considerations concerning switching antidepressants If you any have suggestions, please send them to info@tijdstroom.nl. We are looking forward to your feedback.

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https://www.scarevision.co.uk

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The course focuses on the 20% of information across the curriculum that accounts for 80% of what comes up in the exam.

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Module 0 IF YOU ARE NEW TO THIS
For individuals who are new to the NHS and primary care, learning consultation skills is critical to their success as healthcare professionals. In primary care, healthcare professionals work directly with patients, often on a one-on-one basis. As such, they must be skilled in communication, active listening, and empathy to provide effective care
Module 1 SKILLS FOR BEGINNING CONSULTATIONS EFFECTIVELY
This module will help you to get ALL your consultations off to a good start. Investing in the beginning makes for smoother consultations overall. Find out how to go home with energy to spare.
Module 2 SKILLS FOR BUILDING EFFECTIVE RELATIONSHIPS
When clinician and patient "get on the same page" and work collaboratively together, evidence shows better clinical outcomes, fewer errors and increased satisfaction for clinicians and patients alike. Develop your empathy skills and discover how 40 seconds of empathic interaction can have long lasting effects.
Module 3 SKILLS FOR EFFECTIVE INFORMATION GATHERING
The ear is as mighty as the scalpel. Accurate diagnosis depends on great listening skills. Find out how your listening ear can be more effective in this module.
Module 4 ESSENTIAL SKILLS FOR EFFECTIVE EXPLANATIONS AND PLANNING OF PERSONALISED CARE
The simple, yet highly effective, skills described this module will help clinicians to create explanations that make sense to patients. Then it is easy to develop care plans that are personalised to each individual's unique needs.
Module 5 ADVANCED SKILLS FOR EFFECTIVE EXPLANATIONS AND PLANNING OF PERSONALISED CARE
Uncertainty, long term care, Persistent and Functional symptoms as well as mental health needs may lead to complex consultations. This module empowers clinicians to face these interesting situations with more confidence.
Module 6 SKILLS FOR EFFECTIVE ENDINGS TO THE CONSULTATION
Learn how to end consultations skilfully in this module. An effective ending is safer, results in fewer complaints and ensures clarity about the next steps for clinicians and patients.
Module 7 SKILLS FOR MANAGING TIME EFFECTIVELY
Time is our most precious resource. This module sets out skills for using time effectively, meaning that the time that clinicians and patients spend together is more productive.
Module 8 INSPIRATION AND REJUVENATION
The chapters in this module can give your mind a refreshing break, offer interesting thoughts to inspire your day and provide an effective boost to your learning.
Module 9 EFFECTIVE METHODS FOR TEACHING CONSULTATION SKILLS.
Mainly for educators, clinical supervisors and trainers, this module explores the tried and tested techniques that make for effective consultation skills education. From engaging your participants and developing effective feedback, through to creating really effective skills rehearsals and role plays, educators will find resources to support training in all environments.
Module 10 USING CONSULTATION SKILLS IN COMPLEX CONVERSATIONS
Effective consultation skills for more complex situations, explores the skills needed for some of the more delicate and complex situations that clinicians need to discuss with their patients. This module is about skilled conversations, rather than specific skills. This will always require most of the skills from the TALC Modules 1 to 7, often applied with more awareness or more intensity or combined together in new ways to meet the circumstances.
Module 11 HOLDING THE CALM - SKILLS FOR TIMES WHEN THE CONVERSATION BECOMES AGGRESSIVE OR ABUSIVE