The Principles and Practice of Primary Care and Family Medicine

Asia-Pacific Perspectives

John Fry, Nat Yuen

• Publisher: CRC Press
• Year: 2018
• Print ISBN: 9781857750454
• eBook ISBN: 9781315345949
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Guidelines are powerful instruments of assistance to clinicians capable of extending the clinical roles of nurses and pharmacists. Purchasers and managers perceive them as technological tools guaranteeing treatment quality. Guidelines also offer mechanisms by which doctors and other health care professionals can be made more accountable to their patients. But how can clinicians tell whether a guideline has authority and whether or not it should be followed? Does the law protect doctors who comply with guidelines? Are guideline developers liable for faulty advice? This timely book provides a comprehensive and accessible analysis of the many medical and legal issues arising from the current explosion of clinical guidelines. Featuring clear summaries of relevant UK US and Commonwealth case law it is vital reading for all doctors health care workers managers purchasers patients and lawyers.

1

Health Disease and Care in the Community: Challenges and Dilemmas

i. Introduction

John Fry

Although health care is rightly regarded as a human right, its implementation creates considerable dilemmas for the providers. Expectations and demands are almost infinite, but resources are definitely finite. The challenges facing us all are how to provide comprehensive, equitable and appropriate care within the limits of available resources.

What is ‘health?

The World Health Organization’s utopian definition of health, as ‘a state of complete physical, mental and social wellbeing and not merely an absence of disease’ is a distant and elusive mirage. Although by this definition probably less than 10% of the population is ‘healthy’ at any time, nevertheless it must be a target to be aimed for.

In 1978, the World Health Organization promoted its policy of’Health for all: 2000’, creating an equally impossible target. Translated into reality, the aim should be to achieve ‘Health care for all by the year 2000’.

Such a goal can be achieved only through strong and effective primary health-care services that are well conceived, well planned, well promoted and well supported.

What is ‘disease’?

The dividing lines are blurred between health, disease, illness, sickness, dysphoria and general non-health. Whereas secondary hospital specialists are involved in the classification, diagnosis and treatment of more serious ‘diseases’, those in primary general care are involved more with minor and chronic diseases and undifferentiated collections of symptoms.

There are many ways in which non-health and disease can be measured and recorded; all have weaknesses and drawbacks because of inevitable difficulties of definition, precision, validity and reliability. Despite this, the available forms of data are important for comparisons and for highlighting problems and setting goals. Data are available on rates of:

• mortality
• morbidity
• infant and maternal mortality
• life expectancy.

Differences between countries and places depend on many factors beyond the medical services provided, but it is surprising how similar these indices are in SE Asia.

What is ‘care’?

Good care has to be ‘the art of the possible’. Its limitations are as important as our optimistic expectations of the latest medical technologies. It has been said (somewhat ungrammatically) that doctors can only ‘cure sometimes, relieve often, comfort always and prevent hopefully’.

The mortality of life is 100%. The objectives must be to prevent avoidable premature death and disabilities, to cure when possible, but always to remember that the primary roles of the family doctor are to relieve suffering and to support and comfort the sick and their families.

It is also necessary to accept the ‘insoluble equation of health care’, which dictates that ‘wants will always be greater than proposed needs, which will always be greater than available resources’.

Faced with such dilemmas, the challenge for physicians, providers, planners and politicians must be to make the best use of what they have. This requires good data and information, and a critical evaluation of the usefulness of activities based on good cost-benefit measures. These activities apply to all levels of health care, from national policies right down to the work of a primary-care general practice or clinic. At each level, questions have to be posed.

• Who requires care and who should provide it? Special at-risk groups should be defined and targeted. It should not be assumed that the primary physician has to do everything: a team approach is best, with shared care being allocated to nurses and others in a collaborative manner.
• What care is possible and what has been shown to be effective? Constant review and reappraisal are essential.
• How is care provided? It should not be assumed that present methods are the best, or that they are unchangeable. Constant experimentation and review are necessary.
• Where is care provided? Many options and models are available, from the single-handed primary-care physician working alone, through partnerships and groups to large clinics or hospital units. Sensitive planning and political decisions are necessary to decide on the best ways and best places to provide primary care in the community. Again, the present systems must not be accepted as inviolable.
• When to care? This relates to the possibilities for primary, secondary and tertiary forms of prevention. Immunization, screening, early diagnosis and treatment emphasize the community aspects of primary care, with its responsibilities beyond the doctors’ offices and the hospitals.
• Why care? This question comes back to the issues of why particular promotional, clinical, diagnostic and therapeutic activities are carried out. There should be good positive reasons.

These questions and answers lead inevitably to further issues for consideration: what are the priorities and who should decide? What should the roles of consumers, patients and the public be in deciding what is possible within finite resources? How and where should rationing be applied? What checks and controls should be introduced to implement policies? How should outcomes and benefits be evaluated?

Current realities

We are at a crossroads: health care is no longer the sole province of the medical profession. In developed countries in SE Asia and elsewhere the total cost (if self-care is included) is almost 10% of the gross national product (GNP), and rising. Health-care provision, costs and organization can no longer be left to doctors and patients, but require increasing government involvement.

Primary health care is an essential keystone in all health services. It has to be recognized as such, since the rest of the health system depends on its quality and effectiveness.

ii. Social, Environmental and Economic Determinants

Anthony J Hedley

Chamber’s Dictionary defines health as ‘a sound bodily or mental condition’ or ‘a condition of wholesomeness’. Dorland’s Medical Dictionary borrows from the World Health Organization definition (see page 2). The Encyclopaedia Brittanica adds to this very general statement the emphasis that our perception of personal health depends on the extent to which we can cope with our environment. In the late 19th century, Karl Marx put forward an economic definition of health as ‘the capacity to do productive work’. In that sense our biological state of health might vary considerably depending on the demands which we make on our body in order to complete our activities of daily living, and our subjective feeling of health may have very little to do with the presence or absence of specific diseases. Many of us would regard a reasonable state of health as being a condition which allows us to eat, sleep, achieve normal bodily functions, enjoy freedom from pain and perform our expected quota of daily tasks. Some impairment of our health may result from a variety of symptoms, but whether we regard them collectively as a disease may depend on the type of symptoms and their severity. Teething trouble in infants, morning sickness in pregnant women, backache in building workers or headache in students might all be regarded quite differently from other problems such as chest pain requiring drugs for its relief or the need to take insulin to control blood sugar levels. The reader is invited to define what he or she would consider to be a minimum acceptable state of healthy living.

The personal characteristics and social circumstances of individuals often give rise to marked variations in subjective assessments of health and self-reported illness. For example in males in the United Kingdom (Table 1.ii.I)¹ there are marked gradients, within different age groups, in the personal assessment of health by occupational groups. This type of patt...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Contributors
• Foreword
• Preface
• 1 Health, Disease and Care in the Community: Challenges and Dilemmas
• 2 Patients and Consumers
• 3 Provision of Health and Medical Care: Systems, structure and service
• 4 Health Economics
• 5 Primary Health Care and Family Medicine: Coping with work, demand and expectations
• 6 Practice Organization and Management
• 7 Data and Information Technology
• 8 Education and Training
• 9 Assessment and Continuing Medical Education
• 10 Research
• 11 Quality Assurance
• 12 Laws, Ethics and Standards
• 13 The Emergence of Family Practice
• 14 The Past Present and Future
• Index