By Gene Feder
GP and Professor of Primary Care
Centre for Academic Primary Care
I recently took part in a debate hosted by the Centre for Primary Care and Public Health (QMUL) where I argued that the future quality of the NHS depends on academic primary care.
The vote at the start of the debate: in favour 16, against 11, abstaining 2.
My pitch was based on the challenges of developing integrated health (and social care) for our aging population, a patient-centred shared decision-making model of medical practice, and turning back the commercially (and specialist) driven tide of over-diagnosis and over-treatment. The future quality of the NHS requires those challenges to be met and will depend on a vigorous primary care-based system. And that will (in part) depend on the work of primary care academics. I reminded the audience that I was using the term “academic” to mean having to do with education and research, not its other definition: “unpractical”.
Medical education is still dominated by specialists, with the proportion of teaching in primary care and primary care in the curriculum actually declining. The quality of the NHS depends on skilled GPs working in primary care teams. Family medicine or primary care internationally is consistently associated with more equitable health care and health outcomes. Primary care academics need to make a bigger contribution to medical education to ensure the quality of primary care in the NHS. Health care is full of decisions: to do or not do that test, to prescribe or not prescribe that drug, to recommend or not recommend that psychological treatment. Most of the evidence for those decisions still comes from secondary or tertiary care.
To ensure the future quality of the NHS we need that evidence, including articulating the questions that need answering, from primary care. We need primary care academics to do that. In the UK and, to some extent internationally, departments of academic primary care have led in the development of mixed methods, interdisciplinary research with vigorous patient and public involvement. We need that research to improve the quality of NHS care.
My argument was opposed by Mike Gill, ex-medical director of an acute trust and now innovator of a primary care based project. Jonathan Tomlinson, GP in Hackney, and exquisite blogger seconded me and Jens Foell, GP and medical educator, added to the opposition.
Mike’s attack on the proposition was that innovation and quality had other sources, and did not need primary care academics. He emphasised innovation on the ground and good ideas for quality improvement from social care, mental health, even from enlightened physicians. Both he and Jens highlighted the lack of impact of primary care academic activity and its ivory tower nature. Jens also contrasted the social determinants of health with the marginal benefit of health care interventions (somewhat missing the point of the proposition). Jonathan talked about the role of primary care research, particularly qualitative studies that started from the patients perspectives, such as Jo Kai’s ground breaking research on consultation with parents and their children.
Members of the audience then waded in on either or, sometimes, both sides of the debate, some unconvinced about the role of primary care research, others saying that they had changed their practice as a result. The disagreement boiled down to whether you thought that academic primary care was a necessary (but not sufficient) condition of improving quality of the NHS or not necessary, and dispensable. The final vote, albeit with some audience attrition: 13 for, 10 against and 3 abstaining.
So, I couldn’t have been that that convincing if I lost votes. Time to dissolve the electorate! File under: the problem with voting. Another recent event can go in that file too…