Academic primary care in Europe: is development still possible?
Francesco Carelli Professor FM in Milan and Rome EURACT Council, Executive Board
The function of primary care in the various countries in Europe differs in as far as the structure of health care is concerned.
There are two contrasting models:
1)as the first provider of care in the community, co-ordinating access to more specialized ( hospital based ) care;
2)working in competition with other medical providers.
When the structure of primary care is so different, it becomes difficult to perceive primary care as a coherent discipline. It has been a fundamental achievement of WONCA Europe and academic primary care in general, to demonstrate the coherence of the discipline of primary care behind these differences. This can be summarized under two headings:
1.Features of the medical generalist:
-care for all, unselected health problems in all patient groups;
-early signs / symptoms;
-combining cure, care and prevention;
-emphasis on effective and efficient diagnostic and therapeutic interventions
2.Features of the personal doctor:
-continuity of care;
-empowering individual health and strength ( health promotion );
-addressing individual, social and cultural norms and values.
The keys to the academic agenda that can be drawn from these principles are the empirical data of routine practice – epidemiological surveillance. Irrespective of the health care system, of all health problems experienced, most are never presented to an health care professional. This is the domain of self – care and lay – care. If professional medical care is sought, this professional is the family doctor, with referral for hospital – related care only needed for a minority. In the end, of all episodes of illness, only a small selection ends up in a academic or teaching hospital.
In the first place, this insight in instrumental in addressing better the health needs and demands of the community. Primary care provides the essential interface with the community, which comes forward in its potential for individual prevention and health promotion.
Epidemiological surveillance has enabled a detailed description of the clinical domain of primary care, including the large number of health problems that are more or less exclusively treated in primary care. The curriculum reforms that currently mark the changing world of medical education are pushed by the unique expertise of EURACT in opening – up general practice to undergraduate and postgraduate teaching. Teaching is becoming much more relevant to the issues of health, illness and disease in the community ( European Definition and EURACT Educational Agenda ).
The interface between primary care and the community reflect the need to include the norms and values of the community in the shaping of high quality medical care, in developing the methodology to combine and integrate professional and patient’s views.
The clinical spectrum that is by and large selectively encountered in family medicine can consequently only be studied in family medicine. There is an urgent need of more research of the most common diseases. “ The more common, the less studied “ is an observation with far reaching consequences for the research agenda of primary care. The current increase in primary care research is only the start, but reflects the great success of research expertise building. The agenda is substantial. Including efficacy studies and analysis of effectiveness and efficiency of a large variation of primary care interventions. It requires programme building, with centre of excellence for the development of innovations under optimal primary care conditions, followed by systematic translation to real life practice conditions.
As there is the need of research and development in every country, there is the need of creating adequate conditions. Transfer of experience and expertise from country to country can be powerful factor in fostering primary care around Europe. Family medicine research has to take into account the personal and social complexity, with consequences for the study methods and techniques. Language is a key method in family medicine and its research, and translation forms both a barrier and a facilitator to the contextual complexity of research.
Translation and implementation of innovations are in no way unique for family medicine, but special status for family medicine come from being the single largest group of physicians in every country and consequently with the largest variation to cope with. Innovations have a different status than in hospital specialities: introduction into daily practice is only relevant if it can be brought to each other and every practice. This is an important difference with hospital care, where centres of excellence may provide services that cannot be introduced everywhere.
The last and most exciting aspect of the international exchange has directly to do with the outcome of research. Family medicine is a broad clinical field and research centres and finance are scarce. In addition, successful research leads to concentration and specialisation. A task distribution with much more eye for the possibility of exchange might provide a strong support for the development of the discipline.
The developments in Europe, with more emphasis in family medicine and more emphasis on EU research budgeting, present a challenge. Family medicine can capitalise on this by presenting itself much more in its international European networks. This would open the possibility of systematic planning of family medicine involvement in clinical research, with a consequent strengthening of the evidence base of patient care.