Primary Care
What is Health?
What is Health? The World Health Organisation defines 'health' as 'a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity'. Does the provision of health care or medical care automatically bring about good health? The answer is NO!
Thus the aptness of the conclusion from Roy Porters' excellent medical history "The Greatest Benefit to Mankind":
"The close of my history thus suggests that Medicine's finest hour is the dawn of its dilemmas. For centuries, Medicine was impotent and thus unproblematic. From the Greeks to World War I, its tasks were simple: to grapple with lethal diseases and gross dis-abilities, to ensure live births and to manage pain. It performed these with meagre success. To-day, its mission accomplished, its triumphs are dissolving in disorientation. Medicine has lead to inflated expectations, which the public eagerly swallowed. Yet, as these expectations become unlimited, they are unfulfillable: Medicine will have to re-define its limits even as it extends its capacities."
Life in the 21st Century, A Vision for All is contained in this World Health Report 1998. Articles and links that are pertinent to health and health-related issues are made available here:
Healthy Environments in relation to noice, air quality, housing etc.
Poor Housing and Ill Health: A Summary of Research Evidence.
Protection of the Human Environment from World Health Organization.
Forging the Link Between Health and Human Rights illustrated examples of many connections between health and human rights that appeared in the statement issued in relation to the 50th Anniversary of the United Nations General Assembly's adoption of the Universal Declaration of Human Rights.
Addressing Health Disparities. The first NIH definition of "Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States".
Strategy for Social Cohesion and Quality of Life. Recent years have brought a growing realisation that social cohesion is an essential condition for democratic security. Divided and unequal societies are not only unjust but also cannot guarantee stability in the long term. Social cohesion has been identified as "one of the foremost needs and an essential complement to the promotion of human rights and dignity". There is a need to work together in order to build more cohesive societies in which the risks of social exclusion will be minimised, in addition to focussing on the needs of the poor and marginalised members of society and to seek to strengthen those forces that help to create social solidarity and a sense of belonging.
Tackling Health Inequalities: consultation on a plan for delivery. The purpose of this document is to consult across Government and across sectors at national, regional and local levels on how the national health inequality targets in the areas of life expectancy and infant mortality will be delivered.
Lifestyle and Health Smoking is one of the most researched area of "social habits" that affect health adversely. It is not just confined to direct smoking but also to passive smoking. Thus its impact on the health of infants and children exposed to passive smoking is phenomenal. "Tobacco use remains the leading preventable cause of death in the United States, causing more than 400,000 deaths each year and resulting in more than $50 billion in direct medical costs."
Tobacco Information and Prevention Source
- is a CDC web-site that provides very comprehensive information on tobacco and smoking
Tobacco Control Resource Centre - A resource for doctors.
Healthy Living from the Health Evidence Bulletins-Wales.
Poverty and Health "Poverty is like heat; you cannot see it; you can only feel it; so to know poverty you have to go through it." Adaboya, Ghana.
Poverty is a multidimensional phenomenon, encompassing inability to satisfy basic needs, lack of control over resources, lack of education and skills, poor health, malnutrition, lack of shelter, poor access to water and sanitation, vulnerability to shocks, violence and crime, lack of political freedom and voice. The following web sites illustrate the impact of poverty and human development on health.
Goals for the 21st century and the strategies to achieve these goals will go a long way to reduce the impact of poverty on health.
Joining together to combat poverty - Everybody welcome and needed in BMJ's recent Editorial
International Poverty and Health Network
Monitoring poverty and social exclusion 2000
Quantitative Techniques for Health Equity Analysis: Technical Notes. Have gaps in health outcomes between the poor and better off grown? Are they larger in one country than another? Are health sector subsidies more equally distributed in some countries than others? Is health care utilization equitably distributed in the sense that people in equal need receive similar amounts of health care irrespective of their income? Are health care payments more progressive in one health care financing system than another? What are catastrophic payments? How can they be measured? How far do health care payments impoverish households? Answering questions such as these requires quantitative analysis.
Unemployment and Health This article in its concluding remarks said "Although the relationship between unemployment and health is complex and varies for different population groups, there is consistent evidence from different types of studies that unemployment is associated with adverse health outcomes. Health selection effects do occur, but longitudinal studies provide reasonably convincing evidence that unemployment has a direct effect on health over and above the effects of socioeconomic status, poverty, risk factors, or prior ill-health."
Primary Care defined
What is Primary Care? The definition for primary care proposed by health professionals and politicians alternates between five generic categories. Each category can be interpreted differently. Sometimes these definitions overlap. Sometimes they do not. These categories include:
1) Services rendered by primary care practitioners
2) A process, such as the entry point into the health care system
3) The organisation of care, or the means by which the two goals of a health services system--optimization of health and equity in distributing resources-- are balanced
4) A set of attributes characterised by accessibility, coordination, continuity, comprehensiveness and accountability
5) Patient-oriented, community-based care, with some definitions of primary health care not only including but also requiring the active participation of nurse practitioners and certified nurse midwives
While broad agreement exists that a core group of physicians qualifies as primary care practitioners, disagreement arises on the designation of other physicians who claim to be primary care providers. It is very important to settle these claims when designing the health care system around primary care, because it must determine who primary care providers are, how they are going to be paid, and what kinds of incentives they will be offered to organise their practices.
The failure to define primary care by its clinical and technical knowledge and the skills and services that are involved creates vagueness around the concept. Without agreement about a common clinical basis for primary care, there will be disagreements about who provides primary care, how they relate to each other, and how they should relate to their patients. Professional consensus on these issues is a critical step toward building the health care system around primary care to enure its success.
Though many definitions of primary care which is also known as general practice have been proposed, one of the most frequently quoted is the Leeuwenhorst definition from 1974: "The general practitioner is a licensed medical graduate who gives personal, primary and continuing care to individuals, families and a practice population irrespective of age, sex and illness. It is the synthesis of these functions which is unique." These are two articles from the BMJ that looks at General Practice - time for a new definition and The specialist of the discipline of general practice. Semantics and politics mustn't impede the progress of general practice. The suggested new definition of general practice is as follows:
"The general practitioner is a specialist trained to work in the front line of a healthcare system and to take the initial steps to provide care for any health problem(s) that patients may have. The general practitioner takes care of individuals in a society, irrespective of the patient's type of disease or other personal and social characteristics, and organises the resources available in the healthcare system to the best advantage of the patients. The general practitioner engages with autonomous individuals across the fields of prevention, diagnosis, cure, care, and palliation, using and integrating the sciences of biomedicine, medical psychology, and medical sociology."
The American Academy of Family Physicians has four definitions taken together. They describe the care provided to the patient, the system of providing such care, the types of physicians whose role in the system is to provide primary care, and the role of other physicians, and non-physicians, in providing such care. The definitions can be found at the AAFP's web-site on Primary Care.
What primary care is in relation to secondary and tertiary care is aptly illustrated by this section of the introductory chapter of Primary Care - Concept, Evaluation, and Policy by Starfield, B. M.D., M.P.H.
Primary Care Issues
A strategy for tackling health inequalities in the Netherlands. Socioeconomic inequalities in health are a major challenge for health policy worldwide. The Netherlands has pursued a systematic, research based approach to develop a strategy for reducing these inequalities. Twelve evaluation studies were conducted to study the effectiveness of different interventions. A government advisory committee developed a strategy covering four different entry points for reducing socioeconomic inequalities in health, containing 26 specific recommendations and 11 quantitative policy targets.
WHO calls for countries to shift from acute to chronic care. The World Health Organisation says in its new report that "Primary care providers in developing countries are ill equipped to deal with chronic conditions". It also points out that "this emphasis on acute care is no longer adequate to address changing needs and it warns that as long as the acute care model dominates, expenditure will continue to rise without corresponding improvements in populations’ health status". Innovative Care for Chronic Conditions: Building Blocks for Action can be accessed on the WHO’s website.
Primary Care, Equity, and Health in An International Context is a very interesting Keynote Address given by Starfield, B. M.D., M.P.H. at a Work-in-Progress Seminar on Health & Healthcare in Changing Environments: The Malaysian Experience on April 22 & 23, 2000 in Kuala Lumpur.
Clinical Governance is a framework through which NHS organisations are accountable for continously improving the quality of their services and safeguarding high standards of care by the creation of a systematic set of mechanisms that will support staff to deliver a new approach to quality in which excellence in clinical care will flourish. The WISDOM Centre has pioneered the use of a combination of a web site and an e-mail discussion group for networked professional learning, running a number of conferences using such techniques. One such forum explore the issues affecting primary care groups, with an emphasis on clinical governance.
Primary care: Core values in a changing world. This article outlined the development of primary care and stated that basic core values passed down by tradition, that included all key relationships in primary care with patients, with colleagues in practices, and with the local communities must be guarded by primary care practitioners. Recognising that these values may be affected by evolution in health care and its delivery, primary care must, ensure that this evolution is a conscious and explicit one, "rather than an erosion left too late to remedy." This is the first in a series of six articles reflecting on the core values that will underpin the development of primary care.
Primary care: Patient centred primary care. The relationship between the doctor and the patient had been described as one of open ended commitment on the part of the doctor, a covenant going well beyond the boundaries of any contract with a purchaser of health services, emphasising the importance of both the human and the healing relationships. How many patients want such a covenant and equally, can doctors give such commitment in the changing norms in society? Various models of doctor-patient relationship were discussed. The patient centred approach (based on mutual participation) was seen to have gained increasing support. There is not yet, however, any solid evidence that patient centred care improves health outcomes. This is the second in a series of six articles.
Contracting for general practice: another turn of the wheel of history. This article narrated that general practitioners in the UK had held multiple contracts since the last century, but had become dependent on the NHS for income, to the exclusion of other income streams. With rising expectations, coupled with increasing public resistance to taxation, mean that to maintain income general practitioners may have to develop a wider portfolio of contracts, including private consulting practice in the future, an adaptation to economic and social realities that may not be to their taste. This is the third in a series of six articles.
Developing primary care: gatekeeping, commissioning, and managed care. Primary care is being shaped incrementally by external pressures, especially the need to contain costs and demonstrate improved quality. As a result, primary care professionals, particularly general practitioners, have been encouraged to take more responsibilty to influence health services, rather than just their own professional practice. Scrutiny of quality and cost of care will become more intense. This is the fourth in a series of six articles.
Primary care: core values Primary care in an imperfect market. This article suggests that Medicine is an imperfect market, which does not follow the classic rules of supply and demand and in which, the primary care physician acts as a health broker. Though there are various market models that doctors work in, including the single payer model, the marketplace cannot eradicate the tensions between primary care and specialist doctors, nor can an imperfect model ensure highest quality medicine at the lowest costs. This is the fifth in a series of six articles.
Primary care: core values Patients' priorities. This article discusses the conflict and the differences between the priorities of patients and the aspirations of general practitioners. The author argues that Primary care services could do much more to meet patients' needs through offering extended advocacy. "If primary care is to mean anything to much of the population, it has to be based on the notion that people live with families, partners, or carers and that part of the role of the primary care team is to care for the rest of the family." This is the last in a series of six articles reflecting on the core values.
It's Time to Start Practicing Population-Based Health Care. This article that appeared in the Family Practice Management called for a need for family practices to develop a more methodical and proactive approach to caring for their patient populations, a "systems approach" to primary care especially in today's rapidly changing health care environment. This approach is based on monitoring predetermined outcomes and improving care delivery to optimise care for populations of patients.
Making Medical Practice and Education More Relevant to People's Needs: The Contribution of the Family Doctor. A working paper of the World Health Organisation and the World Organisation of Family Doctors From the joint WHO-WONCA Conference in Ontario, Canada. November 6-8, 1994. This keynote by Alan O'Rourke "The medical curriculum: a little speculation", "The medical curriculum: what should happen to make it more clinically relevant part 1" and "part 2" provide an insight into the thinking of today's practitioners on the emphasis of medical education of the future.
Integrated record keeping is essential if a primary care led health service, integrated services, and patient focused care as key concepts are to be realised in the current health policy in the UK. The extended primary care team is promoted as the means of achieving this essential integrated services, yet has no legal or organisational standing and different members have different professional approaches. This article suggested that this is not a sound basis on which to organise or manage an essential service, unless an integrated primary care record system that integrates the functions of general practice and community health systems is introduced as a prerequisite to successful implementation. Further discussion reiterate that community health services must be considered in proposals for integrated records
However, the issues on patient privacy that need to be taken into consideration is discussed in this article. Integrated electronic health records and patient privacy: possible benefits but real dangers and Health online: the future isn't what it used to be are articles that indicate the need for doctors to discuss how they should prepare themselves to manage future changes.
Is general practice in need of a career structure? This article in the BMJ discussed the relevance of the current training in the hospital environment General Practice in the UK. The author went on to say that training should occur in the context of general practice so that the generalist registrar becomes the equivalent of the specialist registrar, integrating with the multidisciplinary team, and has protected time for professional development and research. The career structure after training should be reorganised to allow development of educational, research, and managerial roles within the practitioners' responsibilities.
Experiences with "rapid appraisal" in primary care: involving the public in assessing health needs, orientating staff, and educating medical students. This article discusses how rapid appraisal can be used to involve the public in the identification of local health needs and can supplement more formal methods of assessing needs. It is best used in homogeneous communities but can be modified to focus on the needs of specific groups of patients
Performance indicators for primary care groups: an evidence based approach This new approach offers primary care the opportunity to further integrate health promotion and health care at the individual and population levels. UK government intends to manage the performance of the "new NHS" by publishing a national framework for assessing performance as a consultation document and primary care groups within health authorities will be judged to have "performed" well on the basis of the indicators listed. The authors present a method to identify important primary care interventions of proved efficacy and suggest performance indicators that could monitor their use.
Whither Continuity of Care? was extentively discussed in this article in the NEJM, in the light of new mandates set forth by HMOs. In situations where there is pressure to cut costs, continued need for medical case managenent in the hospital setting may be done by other than the traditional family physician. Such an arrangement will impact negatively on continuity of care.
WHO urges "coverage for all, not coverage of everything" The report rejects the market approach to health care. Health systems are best financed from central government taxes and by prepayment, and not by charging fees at the point of service, which is unfair and inefficient, it says.
Fast Forwarding Primary Care This is a private sector perspective on the future of Primary Care in the NHS. They envisaged that primary care as epitomised by the GP Practice today will not survive the future. The generalist doctor will become one member (a minority) of a widening team of clinical professionals, making the best use of all available skills, as the range of services offered by the Primary Care Trusts increases. Is there a clinical future for the general practitioner? a BMJ article written by a GP makes interesting reading.
Primary Care - Country Perspective
Australia
Measures of Health and Health Care Delivery in General Practice in Australia. This report describes aspects of patient self-reported health taken from samples of 100,000 patient encounters with GPs. It includes information about 17 main health issues, such as patient weight, cholesterol, vaccination status, mental health, physical activity, smoking and alcohol use.
General Practice Activity in Australia 2000-01 This is the latest (2000-2001) publication in the General Practice Series produced by the General Practice Statistics and Classifications Unit at the University of Sydney, a collaborating unit of the Australian Institute of Health and Welfare. It reports results of the third year of the BEACH program, April 2000 to March 2001. Data reported by 999 general practitioners on 99,900 GP-patient encounters are used to describe aspects of general practice in Australia: the characteristics of the general practitioners and their patients; the types of services the GPs provide; the problems managed and the treatments provided at encounters. Information is also reported on patient body weight to height ratio, smoking status and alcohol use of sub-samples of patients. Changes in the relative rates of management of specific morbidities and changes in management techniques adopted by the GPs are investigated, for the period April 1998 - March 2001,the first three years of the BEACH program.
The Report of the General Practice Strategy Review Group in Australia. These reports of the General Practice Reviews provide an outline of the findings and recommendations of the Review of the General Practice Strategy and the Review of General Practice Training and comments from the Australian Federal Minister for Family and Community Services, Dr Michael Wooldridge. The terms of reference of the reviews were to: review progress on the General Practice Strategy; identify achievements and areas for improvement; and to provide advice on future directions. General Practice: Changing the Future through Partnerships, including the Government's response to the reviews are also available at the Australian Department of Health and Ageing. This article How safe is Australian general practice and how can it be made safer? that appears recently in the Medical Journal of Australia illustrates the attempt made by GPs there at critical incidence reporting as a quality assurance procedure. Current systems for preventing or responding to adverse events are found to be inadequate.
Evaluation of Primary Care Reform Pilots in Ontario Phase 1 - Final Report (Part a)
Evaluation of Primary Care Reform Pilots in Ontario Phase 1 - Final Report (Part b)
Evaluation of Primary Care Reform Pilots in Ontario Phase 2 - Interim Report
Revisiting the Canadian Health Care System from the NEJM -- June 29, 2000
Primary Care Reform: A Strategy for Stability - International data analysis illustrates the present primary care system in Canada as one of the best in the world, yet Canada joins a host of other industrialised countries in exploring fundamental restructuring of its health care system. The articles at this web site discuss the issues related to primary care and form the basis for a thoughtful and stimulating discussion for organised medicine, consumers, and government on the provision of primary health care services. In addition to the above recommended reform strategy, the Ontario Medical Association (OMA) outlines its perspectives on health-care issues in relation to Integrated Health Systems. This is an article on Decentralised health care in Canada that appeared in th BMJ recently in the discussion in relation to the development of the primary care groups that are been set up in various areas in Britain.
Department of Health and Children, Ireland has released two very comprehensive documents outlining its ambitious strategies that will provide a blueprint for the planning and development of primary care and the health system for Ireland over the next 7 - 10 years. The documents, Primary Care - A New Direction and Health Strategy marked a decisive move away from a short-term and limited approach to planning, providing a comprehensive and ambitious blueprint to guide policy makers and service providers towards delivery of the articulated vision in the health system.
"Health and Health Care in Malaysia: Present Trends and Implications for the Future" is a Monograph Series: SM No.3 (1990) published by the Institute for Advanced Studies, University of Malaya, Kuala Lumpur. We are grateful to the author Dr Chee Heng Leng who had given her permission to produce the monograph here. You can access the monograph from the content page which lists the preface and four chapters, vis:
Primary Health Care in Malaysia - Working Together for the Future a paper presented by Dato' Dr Hj Abdul Aziz bin Mahmood, Director of Family Health Development Division, Ministry of Health Malaysia at the National Conference of Managed Care held in Petaling Jaya, Malaysia in August 1996. The Family Health Development Division of the Ministry of Health Malaysia Homepage provides additional information on the public sector primary health care services in the country.
This is a paper entitled Role of Primary Care Doctors in Private Sector by Dr Syed Mohamed Aljunid presented at the First National Conference on Managed Care held in August 1996 in Petaling Jaya. Other papers presented at the same conference can be found in the archives.
Challenges and Prospects for Primary Health Care in Malaysia - a paper presented by Dr Molly Cheah at the "National Conference on Privatisation & Health Care Financing in Malaysia: Emerging Issues and Concerns" held in Penang in April 1997.
Policy Document on Family Medicine in Malta represents the statement which the Malta College of Family Doctors made on its position on the situation of Family Practice in Malta. The College had observed that Family Practice in Malta had lagged behind in its development compared to other traditional medical disciplines as seen by the huge relative discrepancy existing between the financial resources allocated to Hospital Services.
The Development of Primary Care Organisations in New Zealand. This review documents the major recent developments in general practice and primary care. More than 80% of GPs are now members of primary care organisations (PCOs). The review is seen as a contributing to the development of a national primary care policy and strategy.
PCOs are defined as organisations which provide comprehensive, generalist care with primary medical care as the core service, and which have a contractual relationship with the Health Funding Authority (HFA).
Advancing Health in New Zealand - New Zealand Minister of Health sets out the context for the changes in the Health Sector and discusses the influences likely to shape the sector for the next five to ten years. The document also articulates some new themes and messages which are the culmination of policy and service development from experiences gained over the recent years. Thus, New Zealand joins a host of other industrialised countries in exploring reforms and making changes to its health care system. The articles at this web site outline the key goals and policy directions in relation to funding, purchasing and delivery of services and supporting change with better information.
The following documentations on Independent Practice Associations and GP Budget Holding in New Zealand describe the experiences of GPs in the reform process. Experience with rationing health care in New Zealand is an article that describes reform in the area of delivery of health care.
New Zealand's independent practitioner associations: a working model of clinical governance in primary care? The authors of this article believed that the integration of clinical and financial accountability is essential for the development of effective clinical governance. In the NZ example, the independent practitioner associations (IPAs) have been developing a working model of such clinical governance in primary care. The IPAs have a well established infrastructure, including staff, information systems, clinical guidelines, peer discussion groups, and personalised feedback on clinical performance and they have used budget holding to make savings to develop new and better services.
New Zealand's new health sector reforms: back to the future? New Zealand is implementing major changes to the way the health system is organised. The key elements are the development of national strategies and radical restructuring of the healthcare system which include rejecting the current quasimarket approach. However, evaluation plays little part in the health sector restructuring. It is observed that a commitment to evaluation in terms of equity, efficiency, and acceptability would improve the accountability of politicians and might avoid frequent, disruptive, and costly U-turns in policy
Devolving health services to Spain's autonomous regions The 1978 Spanish constitution laid down the rights of all Spaniards to health and to health care. It also established regional governments and a process of profound political decentralisation. This article discussed the devolution process in relation to the General Health Service Act 1986. The main principles covered were: universal coverage, public financing through taxation amongst others that relate to the provision of and a new model of primary care with multidisciplinary teams based in health centres. The article pointed out that though the devolution exercise may bring control of health services closer to the people, it could lead to other problems such as duplication of administration, increased bureaucracy etc. Most important aspects were that national health policies and the concept of a national health service must not be infringed, and existing inequalities on the provision of services must continue to be addressed.
The Future of the NHS: A Framework for debate. This is a discussion paper dated January 2002 published by the King's Fund, an independant charitable foundation working for better health in the UK.
The Labour Government introduced the new Primary Care Act which provides for the Government's model for the future of primary care. The long awaited White Paper was released in December 1996 and the executive summary is available at UK Department of Health. An editorial in the BMJ suggested that in Replacing the NHS market: The white paper should focus on incentives as well as directives. One of the commentaries on the New NHS is on Encouraging responsibility: different paths to accountability. Other discussions are found in BMJ Editorial articles entitled Primary care and the NHS white papers and New Labour, New NHS? while an education and debate article features one of the commentaries entitled How will primary care groups work?
Primary care: opportunities and threats: what the changes mean Following the reforms in the UK NHS including the setting up of the NHSnet, a wide range of pilot schemes are being introduced to offer patients radically different primary care approaches: for most patients through independently contracted partners in small, local general practice surgeries to salaried general practitioners in a large unit run by an NHS trust or other providers. Which of the schemes will be endorsed will depend heavily on how the pilots are evaluated and which outcomes (those affecting services or patients) are given most weight. The following series of six articles will debate the opportunities and threats to the NHS posed by these plans.
Primary care: opportunities and threats Deregulating primary care
Primary care: opportunities and threats: Distributing primary care fairly
Primary care: opportunities and threats Broader teamwork in primary care
Primary care–opportunities and threats: Developing prescribing in primary care
Primary care–opportunities and threats: The changing meaning of the GP contract
From April 1st 1999, the new Primary Care Groups were be "launched" so to speak. The BMJ March 20th 1999 issue carries a host of articles related to this reform in practice. Articles Permanent revolution in primary care, the Editor's choice and the Editorials Reforming British primary care (again) make very interesting reading. Should we fight to preserve the independent status of general practitioners? For and against form part of the debate. A series of articles in the same and subsequent issues under the heading of General Practice are as follows:
Unified budgets for primary care groups
Setting budgets for general practice in the new NHS
A model for clinical governance in primary care groups
Towards primary care groups - Managing the future in Bradford This is the first of four articles showing how primary care groups have been set up in various areas in Britain
Towards primary care groups - Joining up care in London establishing the North Southwark Primary Care Group This is the second of four articles
Towards primary care groups -The development of local healthcare cooperatives in Scotland This is the third of four articles.
Primary Care Group Development:Lessons from the Literature
Fix what's wrong, not what's right, with general practice in Britain from the BMJ - June 17 2000
The NHS Plan This is the editorial article, BMJ 2000;321:315-316 ( 5 August ) on the recent announcement of the UK Health care reform which appears to emphasise on capacity, standards and targets, delivery and partnership.
Reducing health inequalities in Britain. Recent research on inequalities in health in Britain has concentrated on the widening 'health gap'. This study shows how that gap could be narrowed if some of the key social policies of the Government prove to be successful. The research, by Dr Richard Mitchell and Professor Daniel Dorling from the University of Leeds, and Dr Mary Shaw from the University of Bristol analysed every parliamentary constituency in Britain and tested a number of different social policy scenarios, using statistical techniques.
The American health care system had been described as the most expensive and the most inadequate system in the developed world, besides being uniquely complicated. The author in introducing a new series of articles in the NEJM The American Health Care System Revisited -- A New Series made the observation that "The hallmark of the system is its reliance on the private market to deliver and, to a lesser extent, to fund health care. Accordingly, health care is treated as a commodity provided by a huge number of competing organizations." This series is taking off from a previous series published during the period when the Clintons introduced their plan for health care reform. The author went on to note that when the Clinton plan failed, " ... the market took over, and the system is very different now from what it was then -- more fragmented and profit-driven, even as the role of employer-based insurance has declined, payment by government has increased, and the number of the uninsured has grown."
The American Health Care System -- Expenditures
The American Health Care System -- Health Insurance Coverage
The American Health Care System -- Employer-Sponsored Health Coverage
The American Health Care System -- Medicare
The American Health Care System -- Medicaid
The American Health Care System -- The Movement for Improved Quality in Health Care
The American Health Care System -- Physicians and the Changing Medical Marketplace
The American Health Care System -- Wall Street and Health Care
Health Care Reform at the Close of the 20th Century is an article that appeared in the NEJM in June 1999. The article suggests that Americans still appear to wrestle with many of the same health policies of the past, which do not address the fundamental, persistent problems of access to care and its quality and cost. The goals of universal access and comprehensive health care reform have largely faded from view. The entrenchment of the current market system will require more than political will to replace. Public sentiment will be required to hasten such change. This is the link to the letters of response to the above article.
Primary Care in the United States -- The Best of Times, the Worst of Times The article discussed the shifting role of the "humble general practitioner" from second class citizen as they take on the role of "gatekeepers" in managed care health plans in the 90's. Strategies to control medical costs and improve the quality of care often translate into decisions affecting the range of services primary care physicians provide to patients, which patients are referred for specialty care, and the points in disease processes at which referrals are made. This study focused on physicians' assessments of changes in the scope of care provided by primary care physicians and their assessments of the appropriateness of the scope of the care that primary care physicians are expected to provide. The Scope of Practice in Primary Care illustrated some of the responses to the above two articles. Are the Edges of Family Practice Being Worn Away? is a continuation of the discussion on the scope of family practice. These are some of the responses to the discussion.
Putting Power into Patient Choice is an article on the AMA's Council of Medical Service report which calls for a fundamental rethinking of the predominant method of health care financing that would shift decision-making authority from employers to individual patients.
Primary Care - Scope of Practice
Accident and Emergency Care
Providing Primary Care in the Accident and Emergency Department
Recent advances - Accident and emergency medicine
The Last Resort -- The Use of Physical Restraints in Medical Emergencies. Legal Issues in Medicine from the NEJM.
Community services for elderly people - by Barry D. Lebowitz. With an ageing population in Malaysia, health problems of the elderly will take centre stage attention and importance in our future health care system. What is the role of primary care doctors in the care of the elderly in such a system? This article discusses some of the special ageing issues in the development and research on community services for elderly people with mental disorders. These issues, taken together with Normal Aging Index are equally relevant when considering community services for the elderly population as a whole. Long-Term Care for Frail Elderly People -- The On Lok Model is illustrated in the NEJM recently.
The Ageing Population : Developing Coordinated Plan of Care in the Veteran Community - by Dr Syed Mohamed Aljunid discusses the need to seriously consider determining the health care needs of the elderly in Malaysia before planning the services for them. He further discusses the types of services, touching on comprehensiveness and integrated approach to providing such service and also the need to improve quality of care in nursing and old folks homes. Health Care for The Aged - Critical Issues and New Opportunities in Retirement and Nursing Homes was a paper presented by Dr Molly Cheah at the National Conference on The Private Healthcare Industry: Shaping the Future of Malaysian Healthcare towards the 21st Century organised by ASLI in Petaling Jaya in 1995.
Geriatrics and the Limits of Modern Medicine The author of this article wrote of his belief that modern medicine does not work well for old people. Three areas that are particularly problematic for old people are: the medicalisation of everyday life, the primacy of diagnosis, and reimbursement for medical care. He believes that caring for the elderly by attending to proto-illnesses that cause no symptoms but the satisfaction derived from the knowledge based on the statistics of risk reduction is not satisfactory. New models of caring aside, there is also a need to bridge the gaping chasm between what we do and what we know to be true. Due to lack of data based on scientific inquiry, the author suggests that anecdotes and individual opinions collectively may be as useful in the documentation for compassionate care for the elderly. This is the link to a letter of response to the original article.
Geriatrics, Prevention, and the Remodeling of Medicare from the NEJM. Geriatric medicine has focused primarily on the management of acute and chronic diseases in frail older persons, with much less emphasis on the promotion of health and the prevention of disease than there is in health care for children or middle-aged adults. A growing body of knowledge about disease prevention in later life, including important research by Inouye et al. that is reported in this issue of the Journal, provides a valid basis for strengthening efforts in preventive geriatrics. Given its mission and responsibility, the Medicare program is well positioned to lead such an effort on a national scale
Innovation to prevent dependency in old age. Technological innovations may reduce the cost burden of an ageing population.
Building evidence on chronic disease in old age - Standardised assessments and databases offer one way of building the evidence.
Systematic review of day hospital care for elderly people This systematic review that appeared in the BMJ, of 12 randomised trials comparing a variety of day hospitals with a range of alternative services found no overall advantage for day hospital care. Profile of disability in elderly people: estimates from a longitudinal population study, With respect to old age and Social and productive activities in elderly people are articles featured in the BMJ. Rethinking the Role of Tube Feeding in Patients with Advanced Dementia is another article that appeared in the Jan 20th 2000 issue of the NEJM. This is an article on Assessment of the Elderly Patient by Ian Leong Yi Onn, Philip Choo Wee Jin published in the Singapore Family Practice Journal.
Care of older people: Maintaining the dignity and autonomy of older people in the healthcare setting by Kate Lothian and Ian Philp BMJ 2001;322 668-670.
Care of older people: Promoting health and function in an ageing population
Healthcare for older people in residential care -- who cares?
Falls in the elderly: what can be done? Most falls result from a dynamic interaction between intrinsic and extrinsic factors, thus a multidisciplinary approach to their management -- incorporating medical, functional, and environmental assessment -- is likely to be most rewarding. This is an article from the BMJ on the Guidelines for the prevention of falls in people over 65 and letters of reply.
Recent advances: Geriatric Medicine BMJ 2001;322:86-89 ( 13 January )
Recent advances: Palliative care BMJ 2000;321:555-558 ( 2 September )
Caring for family carers in general practice MJA 2002 177 (8): 408-410
Communication problems between dementia carers and general practitioners: effect on access to community support services MJA 2002 177 (4): 186-188
Complementary and Alternative Medicine (CAM)
What is complementary medicine? The following is the definition of complementary medicine adopted by Cochrane Collaboration
"Complementary and alternative medicine (CAM) is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being. Boundaries within CAM and between the CAM domain and that of the dominant system are not always sharp or fixed." What should the professions' role be in complementary medicine? BMJ Editorials in the 20 January 2001; Vol.322, No.7279 issue namely, Integrated medicine and Complementary medicine and medical education besides this article from Intelihealth Professional Network may provide insights to future trend in the practice of medicine. Other related articles from the same BMJ issue that make interesting reading are as follows:
Can doctors respond to patients' increasing interest in complementary and alternative medicine? Commentary: Special study modules and complementary and alternative medicine{---}the Glasgow experience
D K Owen, G Lewith, C R Stephens, and Helen Bryden BMJ 2001;322 154-158
Regulation in complementary and alternative medicine
Simon Y Mills BMJ 2001;322 158-160
Research into complementary and alternative medicine: problems and potential
Richard L Nahin and Stephen E Straus BMJ 2001;322 161-164
Lessons on integration from the developing world's experience. Commentary: Challenges in using traditional systems of medicine
Gerard Bodeker and Ranjit Roy Chaudhury BMJ 2001;322 164-167
Recent advances: Complementary medicine by Andrew Vickers BMJ 2000;321 683-686
ABC of complementary medicine is a series from the BMJ.
Users and practitioners of complementary medicine
Complementary medicine in conventional practice
The manipulative therapies: osteopathy and chiropractic
Hypnosis and relaxation therapies
Unconventional approaches to nutritional medicine
Complementary medicine and the patient
Complementary medicine and the doctor
Alternative (complementary) medicine: a cuckoo in the nest of empiricist reed warblers
Health Prevention and Promotion
Integrating preventive services into primary care practice
Promotion and Protection of Women's Health from WHO
Effective Public Health Practice Project
Screening, case finding and evidence-based guidelines
Systematic reviews of evaluations of diagnostic and screening tests
The Jakarta Declaration on Health Promotion into the 21st Century
Management in General Practice
Clinic Procedures and Guidelines
Executives with White Coats - The Work and World View of Managed-Care Medical Directors.
Organisational development in general practice: lessons from practice and professional development plans (PPDPs)
Glyn Elwyn, Paul Hocking BMC Family Practice 2000, 1:2
Integrating Clinician-Educators into Academic Medical Centers NEJM Sounding Board, September 9 1999
The rise and rise of academic general practice in Australia
Medical Examination of Foreign Workers
Historical Perspective on Medical Examination of Foreign Workers
MOH Guidelines for the Medical Examination of Foreign Workers
Privatisation of Medical Examination of Foreign Workers - News & Views
General practitioners and cancer
Women's Health - A Global Issue
Women's Health is a global issue by Naomi Craft. This is the first of three articles explaining the impact of women's health on the international community.
Life Span: conception to adolescence by Naomi Craft. This is the second of three articles.
The Child bearing years and after by Naomi Craft. This is the third and final of three articles.
Nutrition and physical activity needs of women aged 40 and over
