Theo Schofield, a lecturer in the Department of Public Health and Primary Care at Oxford University Medical School and a practicing general practitioner, discussed real-world examples of physicians working with community groups to improve health and prevent health problems. His practice is in Shipston-on-Stour, a rural area in the Oxford region.Continuing the themes raised in the first two forums (i.e., the supply of generalists and shared decision making), we turned to the British experience for insight into the relationship between generalist physicians and the community they serve. "The first and most important characteristic of primary care in England is that we each have a registered population of patients: on average 1,900 patients per doctor. Virtually every patient in the country is registered with a primary physician, a general practitioner. They have a choice of which physician they register with, and they can move to another primary physician if they wish. The doctors themselves are quite independent. They have a contract with the Family Health Services Authority to provide care for their registered list of patients.
"A second feature of primary care is that we can provide continuity of care. Between 60 and 80 percent of all contact with a primary physician occurs with the same physician. There is a single patient record that is generated when a patient is born, and when a patient moves from one doctor to another, the record moves with the patient. This record contains not only the notes that the primary physician has taken and all the preventive care over the years but also referral letters related to secondary care.
"A major difference between the British system and the American system is the extent to which primary care is based in the community. In the 1850s, when large hospitals were starting to be built in England, there was a debate within the profession about how care should be delivered. Essentially, it was decided that the specialists would get the hospitals, and the primary physicians would care for patients in the community. While only about 15 percent of primary physicians have hospital-admitting privileges, nearly all of us visit patients in the home and have close links to community services in providing home care.
"Given this system, we have all sorts of information available to help assess the needs and capacities of the community: medical records, knowledge of the local community, and the experience of our health-care team members. Our practice produced a profile of the problems we faced. For instance, we were concerned to find a low uptake of family-planning services and a high rate of termination of pregnancies. One of the advantages of having a defined population is that one can work out a rate for events as well as a number. We were able to show that between 1989 and 1990, we had 25 terminations of pregnancy, which is a rate of 14 per 1000. How should we respond to that?
"Our senior partner wrote a letter to the school saying: 'We think you have a problem--a lot of your girls are getting pregnant.' Fortunately, we were able to intercept that letter. We then considered whether or not this might be a health-care delivery problem: maybe there was something wrong with the family-planning clinic, perhaps the timing of the clinic was inconvenient. But we looked at the uptake of other family-planning services and found that people were not going elsewhere. So we set up a working group that involved teachers who were responsible for social skills training, a youth club leader, a social worker, school nurses, a community physician, our health visitor, our practice nurse, and a general practitioner to look at this whole issue.
"Out of this came a number of actions. Our practice nurse joined the youth club as a youth club leader and became known to the teenagers and more accessible to them. We found out about the social skills program, which was a very good program, but it did not actually include training about how to go and see a doctor. Here were people, who until then had been taken to the doctor by a parent, saying how difficult it was to go and see a doctor themselves. So a session on making an appointment and going to a practice was added into the social skills program. We found that the supermarket had teenagers checking out alcohol to people their own age, and the town council objected to renewing their liquor license. The market got their license by stopping the practice of selling alcohol to kids.
"I think this is a good example of using medical records to identify a problem and working with the community to develop its own solutions. On a related note, one of our major challenges is finding ways to consult our patients about the services we are providing. We have tried conventional things: annual patient meetings, suggestion boxes, newsletters, and patient satisfaction surveys. None of these really gives us very much information about what the patients are feeling; they tend toward comments about existing services. And these methods certainly do not involve patients in either planning services or setting the criteria for the way we actually look at our care. We have found it much more effective to have focus groups of patients receiving particular services, and we have done this now with diabetic care, people who have had heart attacks, and mothers of young children. I think there is still a lot of work to be done to find out how patients view our services.
"Implicit in this discussion is the issue of the extent to which the power and the care rests with professionals or with the community. The phrase 'care in the community' is certainly very current with us, and it may well be the same here. But there seem to be three conceptions of what it really means. The first is that people are being cared for by professionals, but at home rather than in hospital; they are home but receive exactly the same care from exactly the same people. The second conception involves a shift from secondary- to primary-care resources and people, but still to professionals and professional care. The third meaning emphasizes the community and the extent to which we are increasing the community's ability to care, to be healthy, and to support people.
"While I have been offering the third perspective here, it is important to realize that there are times when you do need professional power to deal with other groups. One of the current controversies is cigarette advertising. Working through the British Medical Association and the Royal Colleges, we have put tremendous pressure on the government to limit advertising. Advocacy can be very successful. We have a very good track record as a profession--on a national level--working on alcohol, smoking, and seat belts. On a local level, I think the combination of professional power and community involvement can improve the health of our population."