Marshall M. Re-thinking the role of general practice/De huisarts moet zichzelf opnieuw uitvinden. Huisarts Wet 2014:57(11):580-1.
Ingrijpende veranderingen in de financiering en inrichting van het zorgstelsel zorgen ervoor dat de huisarts, die tot nog toe vaak onder de radar kon opereren, een opvallender maatschappelijk profiel krijgt. Dat profiel steunt van oudsher op vier essentiële functies: als verwijzers die de gezondheidsrisico’s van een klacht beoordelen, als begeleiders die de zelfzorg van (chronische) patiënten managen, als hoeders van zorgvoorzieningen en als bewakers van het – soms precaire – evenwicht tussen kwaliteit en kosten. Alle vier deze functies worden uitgedaagd, niet alleen door de hooggespannen verwachtingen van patiënten en politici, maar ook fundamenteler, door de depersonalisering van de huisartsengeneeskunde. De grote nadruk op techniek en evidence-based procedures zorgt voor betere gezondheidsuitkomsten, maar het veronachtzamen van de ‘zachte’ kanten van het vak leidt steeds vaker tot ongelukkige patiënten en zorgverleners, én tot aantoonbaar slechtere gezondheidsuitkomsten. Er is behoefte aan een nieuwe vorm van samenwerking tussen de huisarts, de patiënt en de andere behandelaars waarin meer plaats is voor persoonlijk contact en menselijke interactie.
Door de veranderingen in het zorgstelsel krijgt de huisarts een groter maatschappelijk profiel.
Vier essentiële functies waarborgen het profiel van de huisarts als scharnier in de zorg: verwijzer, begeleider van patiënten, hoeder van de volksgezondheid en bewaker van kosten en kwaliteit.
Deze functies worden bedreigd door depersonalisering van de (huisarts)geneeskunde: er is grote behoefte aan nieuwe samenwerkingsmodellen waarin menselijke interactie meer op de voorgrond staat.
The contribution that general practice makes to individual patients and to their communities has long been recognized, and the trust and respect expressed by patients for their family doctor suggest that this contribution is highly valued. But the contribution that general practice makes to the health system as a whole, and to well-being in wider society, has been less well recognized. As politicians, policy makers, and professional leaders attempt to address the very significant challenges facing their health systems, this role needs to be better understood and actively preserved. If our health systems are to survive the financial and quality challenges that they currently face, all of its parts – primary care, secondary care and the public – must recognize the roles they have to play and work together.
general practice AND wider health system
General practice has four fundamental roles that allow the health system to operate effectively and efficiently. First, GPs acknowledge uncertainty and manage risk. In contrast to hospital practice, there is a low probability of disease in patients seen in general practice. It has been estimated that more than 60 per cent of presentations in general practice cannot be explained in terms of recognized disease processes, although the attention of policy makers has focused on the 40 per cent that can. This does not mean that GPs are doing something unimportant. From a patient perspective, excluding cancer and providing reassurance is as important as diagnosing and treating cancer. So too is using clinical judgement to decide that a child with a fever probably does not have meningitis. If GPs referred all people with potentially dangerous symptoms and signs to hospital, hospitals would implode in weeks. Cooperation between generalists and specialists ensures that risk is managed appropriately for the patient.
Second, GPs manage the interface between professionalized care and self-care. Self-care of the symptoms and signs of ill health is infinitely more common than care provided by health professionals. Minor changes in people’s help-seeking behaviours can have a massive impact on the use of scarce health care resources. There are therefore practical as well as philosophical reasons for encouraging a high level of cooperation between patients and their GPs, promoting shared care and informed self-management, particularly for people with long term conditions. Promoting self-care effectively requires the deep understanding that GPs have of patient’s health beliefs and the environment that they live in, as well technical expertise in encouraging behaviour change. GPs are essential if policies promoting shared and self-care are to be delivered.
Third, GPs recognize and manage the up-stream determinants of health, whilst specialists focus primarily on the consequences of those determinants. The environmental and behavioural determinants of ill-health, such as poor housing, unemployment, diet, exercise, and stress, are widely recognized but highly resistant to remedial action. As members of the communities that they serve, GPs have a deep understanding of what needs to be done as well as having the trust of patients to lead change. General practice is public health with a personal touch and, again, cooperation lies at the heart of effective and efficient care.
Lastly, GPs manage the tensions inherent in the multi-dimensional approach to quality. Hospital specialists rightly focus on the clinical effectiveness and safety of the care that they provide – this is what patients want and need when they go to hospital. But someone in the health system needs to maintain a balanced view of quality, managing what are sometimes trade-offs between good clinical outcomes and waiting times, between providing safe care and containing the costs of minimizing risk, between meeting the preferences of individuals and ensuring fairness to everyone. Taking responsibility for these trade-offs is neither easy nor popular, but GPs do it effectively every day on behalf of the wider health system.
A role under threat
These roles are essential but under increasing pressure. This is not just because general practice has to respond to rising expectations on the part of the public and policy makers, nor just because the sheer complexity and intensity of providing front-line care is increasing year on year. There is a more fundamental challenge that needs to be addressed, the de-personalization of medicine.
Each of the four roles requires GPs to have a close working relationship with their patients and with their specialist colleagues. But general practice has become increasingly technical in its orientation over recent decades and communication with specialists increasingly difficult. Many of the policy drivers for this, such as the emphasis on access, clinical effectiveness, and efficiency, have made an important contribution to the delivery of evidence-based care and in many cases are likely to result in better clinical outcomes. But at the same time they have resulted in an increasingly impersonal health system in which emphasis is on disease and technology, rather than on the patient and humanity. The growing body of research evidence which tells us that the ‘softer’ elements of providing care – relationships, trust, continuity – are associated with better health outcomes, experience, and use of resources, is being ignored.
The result is increasingly unhappy patients and health professionals. Patients want good biomedical outcomes but they want more than this. They even want more than easy access and choice, though this is often how their dissatisfaction with current services is manifest. Patients want to be treated as whole people, not as a cog in the system, a blood pressure or cholesterol that has to be managed. And professionals want to be able to work with colleagues that they know and that they trust, not to have to make ‘To whom it may concern’ referrals. People are now asking for a different kind of interaction, one that re-emphasizes the human side of medicine and builds a new kind of partnership.