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Thursday, 15 June 2017 20:34

The way forward. Possible new challenges for a surviving primary care

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Francesco Carelli

Professor of Family Medicine, University of Milan and Rome

EURACT Council, Director of Communications

Family doctors are better placed than other professions to see what is wrong with all parts of healthcare and better placed to recognise the value of collaborative solutions. Most of the world came to recognise this as long ago as 1978 at the Alma Ata consensus conference and Starfield has demonstrated it in her comparison of healthcare systems – high quality, cost – efficient healthcare needs to have broad – visioned primary care at its heart.


The reason is that generalists have everyday experience of the causes of failure and ingredients of success. Primary care generalist ( not just family doctors ) witness the causes of system failure all the time because patients come to complain about them –not merely failures in one discipline or one hospital, but full range of healthcare experience. Also, primary care doctors often appreciate, better than specialists, that long – term success requires working with others – with families and communities to improve social support, with many varieties of specialist to improve care pathways, with extended primary care teams to deal with a full range of problems.

It may be true that competition is helpful for quality treatment of discrete episodes, but in more complicated situations ( that is most situations ) collaboration between disciplines is a more powerful determinant of quality.

The heightened sensitivity of family doctors to the multiple impacts on health and disease comes from spending so much time teasing apart complex entanglements of social, emotional and medical diseases of patients who present, every few minutes, another “ universe of meaning “ who walks into a family doctor consulting room, often containing myriad intertwined issues, many of which are better suited to low-tech, coordinated local solutions than to expensive specialist referral.

Heightened awareness of the problems does not mean that family doctors are the best people to solve them. Taking family doctors away from consulting rooms takes away the experience that makes their insights so valuable. Historical processes have prevented systematic exploration of the world beyond the practice front door and this has inhibited understanding of how to make whole systems work. General practice is not acting as part of a wider system of care even to support the co-ordination of core general practice work such as end-of-life care.

An early task is to work out which bits family doctors should do and which bits others should be done in partnership with others. Success requires that all family doctors and managers increase understanding about broader issues than the treatment of diseases within general practice. It would be a waste of time for family doctors to divert energy towards the cat and mouse game of hospital system for payments. On the hand family doctors are likely to spot the gaming quicker than others, so a hot line to divert someone else’s attention to it is a good idea.

Effective commissioning will facilitate broad and visionary partnerships for well being and social support. It will monitor existing care pathways and engage with the complexity of redesigning them to become better value. It will cause a culture of reflection and inquiry and increase local skills of applied research, including service evaluations. There needs to be a collective effort to work out how to di these things that includes primary care insights without taking too much of their time.

Commissioning is much more than buying services – it requires annual cycles of collective reflection and coordinated action for a raft of improvements that engage a multitude of people. To facilitate such complex collaborative improvements, we need to become skilled at unfamiliar techniques that help whole organisations, systems and networks to learn and co-evolve, systems mapping, coordinated data capture, large group interventions, learning networks. These will allow large numbers of doctors and managers to meaningfully engage with the complexities of whole system improvement, spreading the load in a way that has high impact of culture and low impact on personal time. There are three stages of commissioning a new service. First to identify what is wrong with the present situation, second to pilot better ways to do things, then to improve relationships between different services to redesign them. It is not enough to merely apply evidence generated in another place because every context is different, with different needs, different range of exiting services and different competencies. In any case, every innovation has unexpected impacts, both good and bad, we need to have alert minds to see these.

We live at a dangerous and dismantling time of history. What happens next could destroy the NHS completely as chasing invoices and over-emphasis on technical fixes makes us sleepwalk into the same mistakes made by insurance policy dependent, disparity filled American health care. Conversely, imaginative and courageous family doctors could lead the renaissance of the NHS, redefining “ public service ethos “ as a disciplined adherence to processes of collaborative improvements. It could set traditional general practice values of family & community care in a modern context where relationships really matter and where the simplistic notion of markets and targets is set inside broad consensus, fuelled by ongoing relationships building across disciplinary and institutional boundaries.

We face a new conceptual challenge in health care and in educating the next generation of primary care providers. A new pedagogy of flexible thinking skills and collaborative practice will be needed to embrace the transformation we are part of, welcome or not. Technology like the internet is more than a form of information exchange, it can empower creative thinking in shared dialogic spaces beyond time and physical limitations. We are all busy. There is a tremendous amount of excellent material available to us in libraries and web pages around the world. Many professionals are learning new ways of thinking, with new tools for joined up working to provide excellent and personalized care for the real people presenting to us each day.


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Size Matters - could small be better?Francesco Carelli, MD, MSc, Professor of Clinical Medicine and Elective Courses Family Medicine, University in Milan and in Roma, EURACT Director of Communications, Italy 

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  • Postgrad course on exercise as medicine is being proposed

    Dear prospective applicant,

    A proposal for a postgrad course on physical activity (PA) as a therapy for non-communicable diseases is currently being evaluated. Hereunder, a two-question survey is being forwarded for your attention in order to assess whether the idea sounds appealable or not.

    Proposed award

    M.Sc in Therapeutic Physical Activity (TPA), with postgrad certificate (PgC) and postgrad diploma (PgD) exit routes

    Proposed specialisation titles[1]

    Holders of PgC, TPA can claim the title of: ‘Clinical exercise prescriber’.

    Holders of PgD, TPA can claim the titles of: ‘Advanced exercise prescriber’ or ‘Clinical and public health exercise prescriber’.

    Holders of M.Sc, TPA can claim the title of: ‘Physical activity - health specialist’.

    Are you sure you know why physical activity is so important?

    Everyone is aware that physical inactivity is a major health concern but, do you know that through the right type of exercise you can prevent or treat at least 35 chronic conditions? In 2007 the American College of Sports Medicine officially declared an important statement: ‘Exercise is medicine’. Moreover, health-enhancing physical activity (HEPA) is important in today’s world not only in view of improving health and wellbeing but also for its economic values. For example, a lifestyle intervention involving 150 minutes of weekly PA was scientifically shown to be significantly more effective than the administration of metformin.

    Possibilities of further career development in exercise prescription

    Exercise prescription, that is, being qualified to professionally recommend the right type of exercise for health does not stop on a one-to-one basis. Do you think you are qualified to: (a) conduct research on PA interventions, and (b) develop, implement and evaluate community or population programmes involving PA strategies? Unfortunately, many wide-scale programmes that are implemented undergo no evaluation to determine how they have worked or what their effects may be. Have you ever imagined the possibility of attending a tertiary course which would be designed to: (a) give you the ability to design a project for the generation of new knowledge and be able to publish it internationally, or (b) train you on how to evaluate wide-scale interventions and how to apply strategies to sustain their continuities?

    A glimpse of the proposed programme of studies

    Intended for:

    The programme of studies is aimed at a wide and diverse cohort of students wishing to pursue any careers in HEPA sectors mainly: exercise prescription; health promotion (policies and practice); general health and fitness industry; and to further their studies (e.g. PhD). It can also serve as an adjunct to enrich one’s knowledge of his / her established profession or career. Examples include: medical practitioners; pharmacists; nurses; physiotherapists; nutritionists; public health specialists; sport medicine specialists; sport psychologists; teachers of physical education (PE); coaches; gym instructors; and personal trainers. Fitness and sport enthusiasts are also encouraged to apply.


    Three years part-time leading to an M.Sc in PA as an effective therapy, with postgrad certificate and postgrad diploma exit routes after the first and second years respectively.

    Mode of delivery:

    Seventy per cent will be delivered online and the rest of the thought units will be offered on a once weekly two-hour evening basis starting at 18.00hrs.

    Admission criteria:

    You should provide evidence of higher educational qualification(s) - normally, a diploma or a degree related to health and / or PA / sport. An award in PE is also ideal. Mature students without these basic qualifications would be required to present evidence of experience related to PA and health.

    Mode of assessment:

    Units will be assessed through the submission of coursework. These will vary from short assessments to long essays. If you would like to progress at Masters’ level, a traditional dissertation or paper in the format for journal publication and a final presentation (in the form of slides or poster) of your research findings will have to be undertaken.


    Unlike other under- and postgrad courses which only cover a fraction from the whole science of HEPA, this comprehensive programme of studies would lead to a specialization specifically on TPA. For careers in promotion, prescription and research of PA, the proposed programme of studies is a must.

    Important notice

    All the above information is subject to change and would eventually have to be approved by the Programme Validation Committee of the University of Malta. Needless to say, your feedback in the next two questions is extremely important.

    Yours in health & exercise,

    Charles Micallef B.Pharm (Hons), M.Sc PAPH (Staff)                                                8th August 2017

    The two questions hereunder.

    1. In view of the above information, would you be interested in applying for this particular postgrad course leading to a specialisation in physical activity with respect to health, that is, a qualification that gives you the right to prescribe exercise for health, even at population levels?

    Yes or No: 

    1. What would you change from or suggest to what is being proposed?

    Please state your name & surname:

    Your current job / profession:

    Please save your changes and forward your reply to Charles Micallef on: This email address is being protected from spambots. You need JavaScript enabled to view it.

    Your cooperation is greatly appreciated.

    [1] In order to professionally recommend exercise for health, you may need to be registered in the appropriate regulatory board and be in possession of a warrant to operate with the respective titles.

    University of Malta

    Written on August 19, 2017
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