Thread by @trishgreenhalgh

A thread on primary health care 101 (#PHC101). Do you even know what primary [health] care is? Do you care about it? Most people, if they were honest, would probably answer ‘not really’ to both. Read on if interested. Mute this thread if not.
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Primary health care (PHC) has 4 defining features:
-First-contact (i.e. you don’t need a referral)
-Accessible (you can get an appointment, whoever you are*)
-Relationship-based (“my GP”)
-Undifferentiated (any illness, any problem—‘generalist’ rather than ‘specialist’)
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* Yeah I know—PHC in UK is not currently accessible to everyone. This is because there is a chronic lack of resources and staff. I’ll return to this later.

For now, let’s focus on PHC at its best, and ask “what *becomes possible* when a country has a strong PHC system?”
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An absolutely CORE concept is social justice. Particularly in low-income settings, PHC is closely aligned with a key goal, which is UHC (universal health care). A strong primary care system ensures that *everyone* has access to basic care. This is humane and saves money.
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In low-income settings, for example, PHC is where we can ensure that girls and women of childbearing age are adequately nourished, and that they receive education, check-ups and treatments (such as iron and folic acid) to help ensure that their babies are born healthy.
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Health checks for pregnant women (with referrals to specialists as needed) illustrates how PHC teams can help ensure that *every* baby gets the best start in life, not just the ones whose parents are well-educated, well-connected or rich.
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Seeing PHC as a contributor to social justice is different from the way some MPs are framing the issue (“since I know what is wrong with me, I could self-refer to a specialist and cut out the middle guy; this proves GPs are a waste of money”).
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The MP here presents PHC as mainly or exclusively a *transactional* service (the GP is seen as a low-skill ‘shop’ or ‘gatekeeper’ to whom you go for a particular request, such as a prescription or a referral). In this model, the GP gets in the way of efficient healthcare.
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In this crude transactional model, the GP is an expert in nothing, since (by definition) a specialist knows more than a GP. This overlooks that the GP is an expert in the *whole patient*, and also in the family, social and cultural context in which illness is lived.
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Yes I know there are rubbish GPs, just like there are rubbish brain surgeons. Stay with me, if you will. I’m talking about primary health care *at its best*, if it’s properly resourced and if its front-line staff are properly trained and not burnt out.
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I was a GP for 25 years. I wouldn’t ever dream of tweeting about any real patient I ever saw. So the cases I’m going to describe in this thread are *entirely fictitious*. But the stories are based on things I’ve seen in real life. Three cases.
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Case 1: Mrs R is 54. She’s a bit overweight, has prediabetes, a grumbly tummy, migraines, is missing her kids who are off at college, and comes to the practice nurse once a month for her blood pressure check. She’s known the nurse for years.
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The nurse always asks “how are you, how are the kids?”. (She gave them their jabs when they were little). One day, Mrs R says “can I ask you about something else, nurse?”. Nurse says sure. Mrs R says “look, it’s a bit embarrassing…”.
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Nurse says “oh come on, we’ve known each other long enough, what’s up?”. So Mrs R says “I’ve been bleeding from my bum.” Nurse knows the protocol for this one. Rectal bleeding might just be piles but it could mean cancer in the colon or rectum.
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Because Mrs R only waited a month before telling the nurse (after all, she knew and trusted her), and because the nurse passed the problem up the line promptly, Mrs R’s rectal cancer was diagnosed early enough to be removed and cured.
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Wouldn’t it be better if Mrs R could self-refer to a bleeding-from-the-bum expert? In general, no. Firstly, it’s often not clear to the lay person which specialist they need to see or how urgently. Does Mrs R need to see a physician or a surgeon for example?
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Secondly, many early cancers start with “embarrassing” symptoms which people only disclose to a clinician they know and trust. My breast cancer began with bleeding from a nipple. If you’re in your 50s, this is an emergency! Most people don’t know that, but GPs do.
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Rule of thumb for a health service: hire GENERALISTS who are ACCESSIBLE to the patients registered with them; support them to build RELATIONSHIPS. Serious illnesses will then often present early and can be fast-tracked to experts.
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Much illness is minor or self-limiting (gets better on its own). Many patients can be reassured that there’s nothing to worry about OR asked to come back in a few weeks if symptoms haven’t resolved. This is why specialists aren’t completely swamped.
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Case 2. JP is 19. His parents were addicts. He was abused and ran away. He sofa-surfed for a few years and is now homeless and begging. He is on methadone replacement for opioid addiction, but he also has asthma and low back pain. He keeps losing his prescriptions.
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JP has been aggressive with doctors and receptionists in the past. He’s now registered with a GP practice next door to a day centre for the homeless. Staff are trained in the challenges of caring for people with ‘complex needs’. A methadone specialist visits the practice.
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Whilst some of JP’s needs (such as his methadone replacement) clearly require ‘specialist’ input, he will also benefit from regular check-ups for his asthma and someone keeping a careful eye on what painkillers he gets prescribed for his backache.
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Should JP be allowed (encouraged?) to self-refer to a specialist for his low back pain? Or should the low back pain be managed by someone who knows his personal circumstances, family background, patterns of consulting and full medication list?
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Ah, says the MP (perhaps), people like JP and Mrs R should still see their GP but *I* should be able to self-refer to a specialist when I know what I’ve got. Hmm. Who will make the decision about the ‘deserving’ and ‘undeserving’ self-referrer?
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Case 3. Mrs L is 65. She came to UK 40 years ago. She was a homemaker and never learnt English. She’s uneasy attending hospital but is very comfortable at her GP’s surgery as several staff are from the same ethnic background. She feels understood and safe there.
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Mrs L has had diabetes and high blood pressure for years. Because her GP surgery is so friendly, she has never missed a check-up. A routine 6-monthly check reveals an increase in her blood pressure, deterioration in her vision, and problems with the circulation to her feet.
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The prompt steps taken by Mrs L’s GP and practice nurse mean that she DOES NOT DEVELOP serious, personally devastating and expensive-to-treat complications such as stroke, blindness or amputation.
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High blood pressure is the commonest cause of stroke. Untreated diabetic eye disease is the commonest cause of blindness in the working-age population. Undetected foot problems in diabetes are the commonest cause of amputation. All these problems may be ASYMPTOMATIC.
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You can’t self-refer for problems you don’t know you’ve got. Primary care delivers ‘RRRS’ for long-term conditions: REGISTRATION (you’re on someone’s list), RECALL, REGULAR CHECK-UPs, and SUPPORT for SELF-MANAGEMENT. This helps prevent strokes, heart attacks, blindness etc.
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PHC in UK is working suboptimally cos the NHS, & primary care in particular, is chronically underfunded. Specialist services are strained, so they shift tasks to GPs. Staff in PHC are exhausted and burnt out. There’s a recruitment and replacement crisis (not enough staff).
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Would it help to make Mrs R, JP, and Mrs L pay £20 per visit? How much would it cost the NHS if these people were given *disincentives* to seek care (present promptly with treatable forms of cancer, have their blood pressure checked before they have a stroke, etc)?
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Whilst some GPs practices are accessible and working well, and many individual staff are working flat out, the system as a whole is at breaking point. The solution is NOT to further erode PHC, which since 1948 has helped to deliver equity and social justice in the NHS.
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Suggestions for a political party seeking to get elected on a social justice platform:
1. Commission some cost projections: what if the PHC safety net falls apart?
2. Take steps to ensure 1 doesn’t happen.
3. Instead of dissing PHC professionals, start a dialogue with them.
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I was born in the NHS. I’ve served as an NHS doctor as well as an academic all my professional life. The current situation is unprecedented and potentially catastrophic. Primary care is the bedrock of the NHS. The weaker PHC is, the more likely the entire NHS will fail.
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