464 y g o o m a h t h p O l l This page intentionally left blank 466 6 Primary care \200 Giving yourself to the highest bidder? 468 A dictionary of primary care acronyms 469 Primar y care and health de \201 nitions 470 Primary care, self-care & intermediate care 472 Prim ary health care teams 474 Small practices or commercial GP clinics? 475 Time, time manageme nt, the busy GP stereo- type, and patient-centered care 476 Medical certi \201 cation 477 The consultation 478 The impossibility of being a good docto r 481 Prevention (and barriers) and screening 482 \200\2236 Primary care clinics 488 Eviden ce-based medicine 489 Protocols, targets, and guidelines 490 The placebo and Hawthorne eff ects 491 Bedside manners in a multicultural world 492 Health education: what \200\231s the point? 494 Patient groups 496 Patients \200\231 complaints & clinical governance 497 Dying at home (palliative care) 498 \200\223501 Records, computers, and decision support 502 Medl ine 504; Premonitions 505 Audit 506 New ways of extending primary care 507 Appraisal, reval idation, & performance 508 Under- and over-performing doctors 509 Patient satisfaction 510 Expert patients: plagues \200 or inspirations? 511 Stopping smoking tobacco 512 Reducing al cohol intake 513 Domestic violence 514 Sustainability & alternative/holistic medicine 515 L iving dangerously 516 Home visits (including one with Nietzsche) 516 Minor illness 517 Are you ready for emergencies/on call? 518 Prescribing and concordance 519 Healing 520 Social m atters 522 Health and social class 523 Purchasers & providers 524 Referral statistics 525 F itness to drive, \202 y, do sport etc 526 Chronic fatigue syndrome 528 Managing obesity 5 30 What to do for the best? 532 Relevant pages elsewhere \200\207Every page in all chapter s. This is why the above contents list is oddly starved of nice meaty clinical topics: don \200\231t worry: they all \201 gure hugely in primary care, but not here because just the list would overwhelm you. See also RCGP GP curriculum rcgp-curriculum.org.uk/extras/curric ulum/index.aspx Fig 1. The correct method for conducting morning surgery: don t look down; don t stop ped- alling. \200\234How do I do it? \200 If I did know what I m doing I wouldn t be able to do it. \200\2351 Is conducting morning surgery a performing art? There is no shortage of fa rce (or tragedy). Because of the huge and unde \201 ned range of primary care, it is said that GPs \200\230need to be the most comprehensively educated of any kind of doctor \200\231. We thank Dr Konstantinos Kritikos, our Junior Reader, for his contribution to this chapter. P \201\201 467 rimary care doctors are specialists in six areas: 1) Diagnosis 2) Health philosophy 3) Dise ase in its earliest phases 4) Prioritizing con \202 icting advice from organ-based special ists 5) Families and their inter- actions with disease 6) Prevention, and balancing of con \202 icting preventive duties. They are personal doctors, responsible for giving comprehen sive and continuing generalist care to those seeking medical help, irrespective of age, sex and state of health. \200\2252 They are the only doctors quali \201 ed to diagnose health and they have special knowledge and experience of disease in its ear- liest phases. They c an answer such questions as \200\234Why doesn \200\231t Miss Phelps ever attend the antena tal clinic? \200\235 and \200\234What must change for her to do so? \200\235. There are fe w instances where GPs can off er more skill and expertise than all other doctors, but there are many times when her understanding of her patient is what counts, and for which no amou nt of expertise can substi- tute. So when, Miss Phelps \200\231s baby dies, to whom does sh e turn in her dis- tress? She isn \200\231t a medical or obstetric problem; she isn \200 \231t even a psychiatric problem: she is Miss Phelps; and the doctor who specializes in her is her GP. \200 . s t e t r a u Q r u o F e r a c y r a m i r P , t o i l E S T \200 e r a c l a n r e t a p Knowledge of the patient and knowledge of disease (from its earliest to its terminal phases ) coupled with the ability to diagnose health (p470) is what comprises this unique discipli ne. If a patient is asking \200\234Am I well, or could I have cancer \200\235 the doctor w ho is always responding by saying \200\234Well, I \200\231m not sure \200 let \200\231s do one more test \200\235 is often a bad doctor, and al- ways an expensive one. Some doctor s have the gift of appraising a patient and knowing instinctively, when to treat, investiga te, refer, or reassure. Nowhere is this instinct more used than in primary care. A chest ph ysician may tell a person that his lungs are healthy, but if, on your way out, he says \200\234Oh, and I \200\231ve also got this pain in my leg \200 \200\235 she may feel out o f her territory. This new symptom undermines her and she is likely to end up saying \200 \234Go and see your GP \200\235, who must then somehow decide whether to reassure, treat, o r refer to another specialist. Coming to primary care after hospital medicine This may be y our \201 rst experience of taking sole responsibility for an episode of care. This may se em isolating, so take steps to make clinical friendships with like- minded staff . Ensure y our plans make sense to your patient. Does he know to return if there are unexpected develo pments? You may need to use time itself rather than some complex scan to make the diagnosis . If tests are needed, they can be done in logical order, rather than all at once which ten ds to happen in hospital. Cargoes of gold: Hospital medicine of- ten deals with a single pr oblem using overwhelming, awesome force (eg shocks, IV antibiotics, scalpels etc) and delig hts in eliminating problem num- ber one now. But primary care takes the long view, sometime s over gener- ations, and wont always try to solve a pressing problem, rather seeking to pr eempt its complications, to set it in context, and to arrange for patients and families to have a psychological advantage when dealing with illnesses that may be interacting in enigm atic ways. We may not say to man with a chest infection \200\234here \200\231s an antibiot ic and stop smoking 40 a day, you idiot \200\235 when we realize he is the partner of last week \200\231s exotic self-harming pa- tient whose psychosis is now mysteriously impro ving. Instead you may hear yourself saying to her: \200\234I think it \200\231s marvelous how you look after each oth- er here are some tips on helping him when his chest is bad . \200\235 Will she \201 nd her new role as reciprocal carer humanizing, and over time, w ill she realize that if she self-harms less he will smoke less? Maybe. Let \200\231s see. \201\201Primary care is full of such excitements, delayed fuses, exploding and unexploding bombs, and collateral blast injury (and delayed rewards, but only when done over years: kee p at it, and today \200\231s dull surgery may one day deliver its cargo of gold into your l ap.) This example embodies the ancient idea that your di- agnoses must be social, spiritual , and psychological, as well as physical. e t u l o s b a e h t f o e i d l l a h s e w , l l e w o d e w f i , n i e r e h w , e r i a n o i l l i m d e n i u r e h t y b d e w o d n e l a t i p s o h r u o s i h t r a e e l o h w e h T \201\201 Giving yourself to the highest bidder? A healthy man is, above all, a man of this earth, and he must, therefore, only live the life of this earth for the sake of order and completeness. But as soon as he falls ill, as soon as the normal earthly order of his organ ism is disturbed, the possibility of another world begins to become more apparent, and the more ill he is, the more closely does he come into touch with the other world. Dostoevsky A part from us health professionals, most people under the age of 40 have no commerce with th is \200\230other world \200\231. But from 40 to 50, most people have at least one illness which will not go away: their passport to Dostoevsky \200\231s world, that never expires. I llnesses multiply with each passing decade, until the day comes when we are full- time citi zens of Dostoevsky \200\231s realm. This explains why young doctors with their exaggerated good-looks and shining health so intoxicate some older patients. We are rare visitors blowi ng in from their \200\230land of lost content \200\231: rare, because, given our training and special knowledge, we might understand. 468 Crime & Punishment INTO my heart an air that kills From yon far country blows: What are those blue remembered hills, What spires, what farms are those? This is the land of lost content, I see it shining plain. The happy highways where I went A nd cannot come again. AE HOUSEMAN; A Shropshire Lad e r a c However many such passports we have, none gives us total access to our patients \200\231 wo rlds: each is unique. But don \200\231t assume that our patients must trav- el alone. Takin g time to \201 nd out what it \200\231s like for our patients is the \201 rst step in f orging an enduring doctor \200\223patient relationship. When patients know we trav- el with them, and that we will not abandon them, they will accept our foibles, even our errors. Ho w can we cope with this big commitment \200\224big enough for one person, let alone a few t housand of our dependent patients? How can we do this without destroying ourselves? \200 \207Do we give in to the highest bidder? Here are some insights from a woman in a crisis wi th too many con \202 icting roles: daughter, mother, lover, and so on: \200\230There is a battle going on for my soul \200 and I cannot just give it to the highest bidder. I have a n interest in it too \200 I have a duty to many people and somehow I will discharge it. I have a duty also to some continuing part of myself. I have \200 ripped open my self-protect ive layers. I see now what I am. It \200\231s not a question of \200\234happiness \200\235 . I don \200\231t value my own more \200\224or much less than anyone else \200\231s. It \200\231s something more lasting: it \200\231s a question of being faithful to an essence \200\231. Sebastian Faulks y r a m i r P On Green Dolphin Street If we spend day after day in surgery without attending to our other roles we are not necess arily better than a person who leaves work on time, so ena- bling a visit to a grandparent, or a dialog with a son, or time for recreation. The medical world encourages the dangerous delusion that we are somehow inadequate if we do not give our all. What gives rise to this is the delusion that the best unit of measurement of our medical lives is the single consu lta- tion. This is how we are assessed, as if there were no valid distractions during consu ltations \200\224as if our own needs were non-existent, and 100% of the focus is placed on the patient sitting in front of us. But what if you should not really be seeing this patien t at all, but should be out on a visit which might or might not be urgent? Or would it be b etter to be on the phone, talking to a possibly suicidal patient who has missed their appoi ntment? Perhaps you need to do all three. Then you will do none of them well. If we are goi ng to be successful in primary care, with its unending responsibilities, we have to recogni ze that the best doctors may not do anything very well.1 The best doctors just make the lea st bad decisions on how to spend their time, and themselves. As with the woman above, they do not simply give their soul to the highest bidder. Don \200\231t feel guilty about this. To give yourself to the highest bidder would be a betrayal: not even saints do this. 1 Most days it is possible to achieve excellence in encounters with at least one patient \200\224try to do so to pre- vent a drift into mediocrity, provided doing so does not under mine your other encounters. 469 An English or quasi-English dictionary of primary care acronyms \200\207If you speak the l anguage, you may eventually come to understand it. ACBS Advisory committee on borderline su bstances; prescriptions thus en- dorsed reclassify special foods (eg without gluten) as a free \200\230drug \200\231. AGMS Alternative general medical services (non-NHS, purchased by PCTs) AiS Associate in training (category of membership of the RCGP; may become a full member when training is successfully completed and MRCGP passed). AKT Applied knowledge test (part of the MRCGP exam) CHI Commission for health improvement \200\224aims to improve standards by: as- sessing NHS organizations and publicly investigat es failure \200\224and checks that the NHS is following national guidelines. It advises on best practice. e r a c y r a m i r P CPN Community psychiatric nurse. DES Directed enhanced services (see LES and NES). DoH/DSS Government department of health/department of social services. DNA Did not attend (for a bo oked appointment \211\210 waste of NHS resources). EBM Evidence-based medicine (p489) or t he journal of the same name. ECR Extracontractual referral, ie no existing contract exists ( \200\230 costly). EHR Electronic health record accessible anywhere in the NHS. FMED3 Form for sick pay, p522. FP10 NHS prescription form. GMC General medical council (a lay-dominat ed statutory regulatory body). IM&T Information management and technology. LES Locally agre ed enhanced service (see NES and DES). LIS Local implementation strategy, eg for IM&T LMC L ocal medical committee (blesses or curses central non-statutory policies) MASTA Medical adv isory service for travelers abroad. www.masta.org MCP Male chauvinist pig; medical care pra ctitioner, -way between nurse & GP. MDU/MPS Medical defense union and the medical protection society. MESH Medical subheadings used in medline searches, see p504. MRCGP Member of the Royal College of General Practition ers (a kind of GP club) NELH National electronic library for health. www.nelh.nhs.uk NES Na tional enhanced service, eg payment for speci \201 ed (non-contractual) nationally-agreed activity. NHS UK national health service: a system for providing universal health care free at the point of use, funded from taxation; the 20th century \200\231s best invention NICE National institute for health and clinical excellence. www.nice.org.uk NMC Nursing and midwifery council (replaces UKCC). NPSA National patient safety agency for reporting criti cal incidents. NSF National service framework (eg for diabetes, heart disease etc, p523). O TC Over the counter medicine; POM is a prescription-only medicine. PACT Trademark of the prescription pricing authority (PPA). PALS Patient Advice and Liaison Service (NHS complain ts body etc, p497). PCO Primary care organization (usually a Trust \200\224PCT). PDP Person al development plan (see appraisals, p508) www.emispdp.com QMAS Quality management analysis system (nationally agreed way of extract- ing data from GP computer systems to quantify quality points for QOF). QOF Quality and outcomes framework (in the UK, getting paid by results, eg if 74% of diabetic patients have an HbA1c <7.4% and BP <145/85mmHg). RCT Randomized controlled trial. SAFF Service and \201 nancial framework \200\224a \201 nancial plan. SFE Statement of \201 nancial entitlement (NHS). SLS Selected list scheme; written on an FP10, this makes Viagraetc free, eg if DM, MS, parkinsonism, prostate ca, spina bi \201 da, cord injury, or polio. SMR Standardized mortality ratios. SPN Supplementary prescribing nurse (p474). TQM Total qu ality management www.eiro.eurofound.ie/1997/05/feature/uk9705113f.html DVLA Driving vehicle licensing authority www.dvla.gov.uk/medical/ataglance.aspx Primary care and health Primary care and distributive justice WHO Alma-Ata statement:3 Prim ary care should \200\230be made universally accessible to individuals and families in the com- munity, by means acceptable to them, through their full participation, and at the cost that the community and country can aff ord to maintain in the spirit of self-reliance \200 [and] addresses the main health problems in the community, pro- viding promotive, preventa tive, curative and rehabilitative services accordingly \200\231. Factors aff ecting access to health include \201 nance, ideology, and education. Six GP job descriptions (Compare t riage clinics with \200\230normal surgery \200\231.) \200 To clear the waiting room ef \201 ciently (kindly if possible) only spending your- self et al to gain speci \201 ed wor thwhile health gains. (No time wasters, please!) 470 \200 \200\234Get me better, doctor, so I can go on doing the things that made me ill \200 \235 \200 To do whatever the patient wants, within the law, usually. (I \200\231m a nice guy.) \200 To deal with local realities (loneliness, addiction, poverty, and mental illne ss) rather than hoping for diagnostic wonders to test your brilliance. To be skilled in: prioritization; delegation; health-need measurement; rationing. \200 To care for people irrespective of age, sex, sexual orientation, race, illness, or status. To make early diagnoses, framed in physical, psychological, and social terms. To make initial decisions about all problems presented or unearthed. To arrange continuing care of chronic , recurrent, or terminal illness. To practice in co-operation with colleagues. To treat via physical and psychosocial interven- tions4 (eg augmenting problem-solving in depression), to prevent disease, and to educate to promote health, reconciling our responsibility to the community. Health \200\207If you haven \200\231t had a dialog with a patient about what c ounts as health for them, and where they are in their lives, you haven \200\231t started to do medicine yet. 7 de \201 nitions to juggle with: 1 Health is the absence of disease \200\224or: de \201 nition 5 2 A state of complete physical, mental, and social wellbeing. WHO 1946 3 A process of adaptation, to changing environments, to growing up and age- ing, t o healing when damaged, to suff ering, and death. Health embraces the Medical Nemesis 6 fut ure so includes anguish and the inner resources to live with it.Ivan Illich 1974 e r a c y r a m i r P 4 Any process enabling the giving, promoting, or engendering of life. 5 Restoring integrity , equilibrium & wellbeing through self-management.BMJ 2011 M Huber 7 6 Acquiring and alloca ting resources to enhance survival and reproduction. All This Rain 8 7 Health is whatever w orks, and for as long. J Stone 1980 All the above have limitations, eg on de \201 nition 1 , everyone is unhealthy all the time, except during coitus \200 Was Charles I healthy as h e laid his head on the executioner \200\231s block? \200 What about a priest in the act of losing his cel- ibacy? \200 Can a heart with a prosthetic valve that is gradually wearing out be healthy? \200 Was Gandhi healthy at the end of a hunger strike? \200 Can animals or babies be healthy? \200 What about death in childbirth? \200\230Answers \200\231 below : Healthy according to de \201 nition: King Charles on the scaff old Fasting Gandhi Babies a nd animals Heart with failing valve Priest losing his celibacy Death in childbirth 1 NO NO YES NO NO NO 2 NO NO YES NO NO NO 3 YES YES NO NO YES YES 4 NO YES YES NO YES YES 5 NO NO YES NO NO NO 6 NO NO YES NO YES NO 7 YES YES YES YES YES NO Measuring health Scores on the health survey Short Form 36 (SF36) are repro- ducible quanti \201 able and valid when combined with a patient-generated index of quality of life ( \200\230name the 5 chief activities/areas aff ected by your condition \200 and rank impor tance of improvements to them \200\231) and a daily time trade-off cal- culation (how much time would you give up to be in perfect health?). By com- bining instruments, defects in on e can be mitigated (eg the SF36 asks if health limits your ability to walk a mile \200\224i rrelevant if you do not need or want to walk much). Health need is the diff erence between the state now and a goal. Needs may be ranked by the distances between states and goals. 471 Why does health matter? Health is one of the few unquali \201 ed, self-evident goods (alth ough it is rather pointless if it brings no pleasure). One person \200\231s health cannot b e achieved at the expense of another \200\231s: if it seems to be, we end up substituting o ne prob- lem for many others (eg global insecurity, through creation of an underclass). Thi s is why health achieves a con \202 uence of foreign and domestic policies of all enlighte ned government ministers, who at least in the UK state unequivo- cally that health improves global security, enhances development, trade, and human rights. 9 Health creates a standar d against which any action can be judged. If you are in a quandary, ask yourself \200\234W hich of my competing actions will promote health among those who have least access to healt h? \200\235 \200\207If we followed the answer just 1% of the time, a benign revolution wou ld be born. What are the determinants of health? One answer is wealth. With wealth come mor e stable political systems, and these are what are necessary for literacy and education to \202 ourish, which in turn lead to easy access to clean water (the key issue, as more tha n 1 bil- lion people have no such access) and the possibility of developing equitable healt h delivery systems. After clean water, the next steps focus on better nu- trition, smaller families, more self-help, and anti-HIV strategies. \200\207How do you move a Western post- industrial population from a low level of health to a higher level of health? Since 2004, U K NHS primary care has been a vast multi- million pound test-bed of a payment-by-results sy stem. Targets can only ever be partially successful, for targets always distort clinical pr iorities (p490). Future determinants of health are thought to rest on: \200 Controlling c limate change and reducing health inequalities. \200 Decline in tobacco consumption in al l age groups. \200 Better health services with more eff ective, more acceptable treatment s. \200 Fewer under-doctored areas (currently de \201 ned as populations where there are fewer than 52.695 GPs per 100,000 \200\224ie a list size of >1898 per whole-time GP) \200 \224and more GPs in deprived areas. Funding more GPs has been calculated as one of the most effi cient ways of reducing mortality. \200 Education capable of in \202 uencing behavi or to \200\201exposure to risk factors. \200 Better protection of the environment and be tter housing. \200 More patient-centered health care, so that patients are not passive re cipi- ents of care, but well-educated partners in the struggle against disease. Core compet encies European Academy of Teachers in General Practice EURACT \200 Dealing with unselect ed problems covering all health issues, co-ordinating care with other professionals in prim ary care and with other specialists. \200 Adopting a person-centered approach, seeing peo ple in their social reali- ties; using consultations to augment doctor \200\223patient rela tionships, with respect for autonomy; to communicate, set priorities, and act together; to provide continuity of care10 as determined by the needs of the patient. 11 \200 Investiga ting incrementally; using time as a tool; tolerating uncertainty. \200 Being able to mana ge many simultanous complaints and pathologies \200\224 acute and chronic \200\224while pro moting health and wellbeing \200\224by applying and prioritizing health promotion and disea se prevention strategies. e r a c y r a m i r P Community orientation includes the ability to reconcile health needs of in- dividual patients and those of the community in which they live. Holistic modeling:1 the ability to use a bio-psycho-social model, taking into account cultu ral and existential2 dimensions of non-reductionist thinking. 1 Holism: (holon is Greek for entity) the tendency in nature to form wholes, that are great er than the sum of the parts, through creative evolution (Jan Smuts 1926). This process is called \200\230emergence \200\231. 2 Existential implies more than just spiritual; it mean s that \200\230everything aff ects health \200\231 (p653). 12 Existential needn \200\231t always mean wearing black jeans and black polo-neck jerseys and singing about one \200\231s angst. \200\234The song is sung, not after it has come to be, but rather: in the singing the song begins to be a song. \200\235 \200\224an example of non-reductionist thinking; see Heidegger. 13 Primary health care Primary care is the 1st contact with health servic- es. 6 models: 1) Ge neral practice 2) Phone advice (NHS direct) 3) Walk-in centers run by enhanced nurses 4) A& E 5) Pharmacies 6) Large clinics (cov- ering populations of >40,000 with a range of skills: GPs, trauma staff , imaging, simple surgery/endos- copy, with on-site labs, physio, and dr ugstore). 472 \200 Primary care core activities \200 Ensuring freedom from want: safe food, wateretc Basic illness treatment \200 Provision of drugs \200 Preventive care (p482) \200 Enab ling Maslow \200\231s hierarchy (p315) Where needed, referrals are made from pri- mary care (in 10% of UK patients) to secondary care, eg district hospitals. Tertiary referral to regional centers may then occur. This sed uctively simple model misses out entirely on the cornerstone of primary health care: the re sponsibility that individuals and families have for their own physical and mental well-bein g. \200\20790% of health problems are taken care of outside formal health systems. Unless individuals and families act on their own initiative to promote their health, no amount of medical care is going to make them healthy. In assessing how good a community is at primary health care, one needs to look not just at medical care, but also at social, political, an d cultural aspects. Ask questions such as: Is society making it easy for individuals to cho ose a healthy lifestyle? and How is society targeting health education? and Is this \200 \230education \200\231 in fact indoctrination? What you are being taught is an amalgam of c urrent prejudice and the choices of this particular culture. The slightest look at history will show how impermanent these must be. Primary health care de \201 ned as a strategy No country is rich enough to give its citizens (and illegal immigrants) everything that medici ne can off er. Hence the need for effi cient use of limited resource. This presupposes an e ff ective sys- tem of primary health care. To be eff ective, this must be accessible; relev ant to people \200\231s needs; properly integrated; have full community participation; be c ost- eff ective, and characterized by collaboration between sectors of society. UK facts \200 GP care costs <10% of total NHS costs ( 20/consultation vs 60 in A&E). \200 90% of illnesses known to the NHS are handled entirely in primary care. \200 26,000 GP Princ ipals in England (GPs with PCT contract) 14,15 + 7000 salaried GPs (paid by Principals) + 1700 locums + 2000 Drs doing foundation-year and specialist GP training (FY1, ST1 \200 \2233) 16 Supporting staff : \200\2063/whole-time GP. e r a c y r a m i r P Intermediate care 17 This type of care lies between traditional primary care and secondary care. It integrates facilities from many areas to address complex health needs which do not require use of district general hospital services. Examples include pre- admission assessm ent units; early and supported discharge schemes; commu- nity (cottage) hospitals; domicili ary stroke units; hospitals-at-home schemes; rehabilitation units. It is one of the mechani sms by which health and social services mesh to allow patients to receive the most appropri ate care. Its main advantages are that it is said to allow: 1 Care close to home. 2 Best us e of new technology, eg information technology, near-patient testing, and phone-activated d evices to summon help. 3 Cost-ef- fective use of resources. 4 Less rigidly demarcated profe ssional roles. 5 Crea- tive integration of working practices. Don \200\231t think of it sim ply as reducing bed- blocking, but it can. 18 It may also be more expensive than standard c are. 19 NB: intermediate care also off ers GPs a route to developing a special interest (GP SI). This option needs careful economic scrutiny: it \200\231s not obvious that such care w ill be cheaper, as someone else has to do the work of the GP while she is do- ing the speci al interest. 20 Reducing waiting times is a key policy driver behind GPSI services, but thi s is not the chief issue for patients. The thoroughness of the consultation and the experti se of the clinician are higher priorities. 21 473 Self-care and empowered self-care Simple self-care constitutes the health activities which we do on our own and within familiy, eg brushing our teeth, or going to bed with aspirins d ur- ing \202 u. Empowered self-care is what can happen when primary, secondary (district general hospital), and tertiary care (eg regional burns units and cancer specialisms) work together with social services within the context of the family life cycle. Crucially, it us es the principles of intermediate care (see OPPOSITE). \200\207Of any health care system, ask how rich and deep are its com- munity roots? How many options are there for the care of this sick old lady who has a bad chest and is temporarily off her feet? If your health car e sys- tem lacks depth, and if ties of religion and family are loose, the only option may b e an emergency admission to a high-technology hospital. Emergency admissions in the UK and many other areas have been climbing inexorably. One important reason is lack of options in primary care. e r a c y r a m i r P Whenever you think of admitting a patient to hospital, ask \200\207What are the other opti ons? Do this not just to save the hospital work, but to force you to \201 nd out what you r patient really wants, and to ensure that the most appropriate level of care is found. Whe n you think of these options, don \200\231t think doctors or nurses? \200\224think universa l health worker. Universal health workers have various skills: \201 nd out about them, an d judge them not according to historic professional codes but according to how good they ar e at empowering self-care. No health service can look after most pa- tients most of the tim e. Empowered self-care in the context of interdepend- ent social and medical services is no t some new option that may or may not be used: it is the only option for health services wh ich aim to look after more than one patient. Without this idea of empowered self-care, hosp itals become places of passive dependency, they get too full, you cannot get people in, and you cannot get people out. NB: if you think that empowered self-care is a cli- ch , try d oing your diabetic clinic without it: you will always fail. Options without admitting: \200 Neighborly help \200 Hospice \200 Sheltered housing \200 Hospital at home \200 Nursing/rest home \200 Social services home \200 Twilight home nurses \200 Domiciliary physio/OT \200 Admission avoidance team \200 Fast-respo nse nursing Empowered self-care entails choice (p315), dialog (p370), knowledge of mental states (p324) , informed consent (p402), literacy/education (p494), par- ticipation in planning and respe ct by professionals for lifeworlds other than their own (p321). We have to harmonize our ca re-plans with patients \200\231 belief systems. So if a man takes strength from meditation, this should feed into the dialogs which inform his empowered self-care. This yields more p atient satisfaction and improved outcomes (such as improved health, reduced pre- scribing, fewer side eff ects, etc): see p517. 22 \200\22325 Barriers to this type of care \200 Peo ple who are rendered helpless and hopeless by unemployment, poverty, and family strife. Oth ers who have diffi culty accessing care include: the homeless, refugees, drug abusers, ethn ic minority groups, and patients liv- ing in rural areas without public transportation. Professionals who want to monopolize and medicalize health. \200 Nations which are keener to take up arms than to vaccinate them. \200 A world which behaves as if it does not kno w the meaning of social justice and equality, and in which rich and poor fail to share comm on objectives \200\224 or simply fail to share anything. Primary health care teams Whenever a task can be successfully delegated, delegate it. The a ntithesis is: If you want a job done properly, do it yourself. Nature favors the \201 rst maxim: when we die all our tasks are either forgotten or delegated, often by default. So t he question is not whether to delegate, but when, and to whom. The principle of team work i s: No member is indispensable; all can contrib- ute. Teams may be small and close-knit, or large \200\224for example the NHS \200\230super surgery \200\231, with doctors, dentists, opticians, a drugstore, and heart clinics.et al Doctors Principals/partners: GPs holding co ntracts with a Primary Care Or- ganization (PCO) and consortia; some may specialize (eg end oscopy), or have a role in the PCO, eg in commissioning care;1 GP non-principals, sessional GPs locums; FY1, ST3 registrars. Medical and other students may also be present. 474 A good question for any partnership to ask is \200\234What is our range of skills, and is postgraduate training being arranged to \201 ll in any lacunae? \200\235 GPs with special interests need not undermine the central role of being a generalist. Community nurses (emp loyed in England by Primary Care Trusts). Activi- ties: post-op visits for dressings and th e removal of sutures, dressing leg ul- cers, and giving \200\230all care \200\231 to the d ying, giving injections (eg to blind diabetic patients), and supplying incontinence and oth er aids catheterizations. Nurse prescribers have additional training and are termed Inde pendent or Supple- mentary Nurse Prescribers (SNP). SNPs only prescribe according to protoc ols once a diagnosis has been made. 26 Midwives They do antenatal classes, clinics, home vi sits, and home deliveries. They have a statutory obligation to visit in the puerperium for the 1st 10 days (she has right of access). At 10 days the health visitor takes over. Health visitors have nursing and midwifery backgrounds, plus health visiting quali \201 cations. Roles: developmental testing of children; immunization advice; breastfeeding; minor illnes s in children; handicap; advice to adults about diet & smoking; implementing health educati on offi cer (p495) strategies; screening of the elderly in their homes; bereavement visits. Practice nurses activities include: \200 Tests: Urine; blood (best delegated to a phlebot omy-trained receptionist, with a \200\230health assistant \200\231 role); audiometry; ECGs ; peak \202 ow. \200 Advice: Diet; travel. \200 Treatment: Ear syringing; injections. \200 Prevention & audit: Vaccinations; BP; cervical smears; family planning/IUCDs (eg holdi ng an English National Board Certi \201 cate). \200 Chronic disease: Diabe- tes, asthma, COPD, heart disease, etc. \200 Chaperoning: Usually she is too busy. Nurse practitioners d iagnose and initiate treatment. Patient satisfaction is high. No increase in adverse outcom es has been found; consultations are longer by 3 \200\2234 minutes, and more tests are done . 27,28 Community matrons have case-loads of 60 vulnerable patients, eg with multiple path ologies such as CCF and falls. She gives home care (active case management) aiming to \200 \201emergency admissions (which fall by 6% on the most optimistic forecasts). 29 Counselors 30% of GP patients have psychological conditions, and to help with these, counselors may b e employed; their role is uncertain (p381). Receptionists and secretaries Receptionists may take on a health assis- tant role taking blood, testing urines, doing BPs, capillary gluco se, ECGs, or au- dits (have they had their hepatitis B vaccinations?) Practice managers lea d on: \201 nance; employment law; tax; risk assessment/ reduction; health & safety; audit ; commissioning care contracts. Others: So- cial worker, psychologist, physiotherapist. Bey ond the surgery: NHS Direct; NHS walk-in services; nurse-led personal medical services; com munity phar- macists, health education offi cers (p495), community physicians. e r a c y r a m i r P 1 Commissioning care may seem something you are not engaged in, but every time we sign a pr escription we are commissioning care, and we all need to take responsibility for how money is spent. 475 Small practices vs huge commercial companies Commercial primary care companies (eg The Prac tice , under contract to the NHS, 30 with loyalties to shareholders, not the communities t hey serve) are new in UK primary care, but polyclinics have long existed in India, Germany, Russia, France, and USA). 40 or more primary care doctors work with dentists, mid- wives, nurses, physios, radiologists, chiropodists, endoscopists, and consult- ants. They aim to d o half the work now done in hospital. Their champions say they are: \200 Cheap \200 Mor e integrated (easy to refer across the corridor) \200 Better equipped \200 Available ou t-of-hours (24/7). But continuity of care suff ers; this is highly valued by patients, 10 a nd gives much job satisfaction to GPs. An example shows the value of continuity of care. One of us (JML) was called to an unrousab le sweating 60-year-old man, whom we admitted to hospital with suspected septicaemia \200 \224which, years later, turned out to be the present- ing symptom of an occult, indolent ma lignancy. We looked after him until his death at home. The continuity of care, not the clin ical details, made the job interesting. But the continuity doesn \200\231t stop at the end of one life. Now, when- ever we see his wife, on trivial and grave problems, we have this s hared bond. When she refused hospital admission for pneumonia and hypoxia, we could use thi s shared bond to induce her, over a day or so, to change her mind. e r a c y r a m i r P The dangers of exhaustion and isolation are not solved by larger practices or polyclinics ( which could add to professional isolation). NB: single-handed doctors are more likely to co mpensate for isolation from colleagues by identi- fying more with patients, which may well help patient centered care.