Lord Darzi's promise of a more holistic approach to healthcare with a greater focus on primary prevention is welcome, but how will we move beyond the rhetoric? If such a paradigm shift is to happen, much of it will have to be delivered in primary care.
Historically, the public health function in primary care has been weak. With the dominant biomedical approach, the focus is on treating illness. Primary prevention is not seen as a core function. GPs, with their one-to-one relationships with patients, often struggle to accommodate a population-wide perspective.
If Lord Darzi's vision is to become reality, we will have to expand primary care's public health capacity by encouraging GPs to become public health champions who can support integrated commissioning.
The Knowsley model
The Public Health Resource Unit is currently working with the Royal College of GPs and the Department of Health to develop a competency framework for GPs with a special interest in public health.
Over the last three years, Knowsley PCT has used GP public health practitioners to build capacity at the primary care/public health interface. The role focuses on three areas: advancing quality, promoting primary prevention and supporting the GP commissioning function.
Not all GPs practise to the same high standards. There is substantial variation between practices in rates of diagnosis, treatment, outcomes and patient experience. Knowsley's GP public health practitioner uses his dual role to address this variation by promoting evidence-based, systematic management of long-term conditions.
There are four stages to this process:
collating evidence of variation in clinical practice;
using this evidence to engage GPs around the need to advance quality;
developing communities of practice - GPs and nurses acting as clinical champions to provide peer review, guidance and support to practices. Currently, three such communities are operating or under development in Knowsley, covering cardiovascular disease, chronic obstructive pulmonary disease and diabetes;
implementing systematic proactive management (by developing local enhanced services, clinical care pathways and guidance).
An early outcome from this process in Knowsley are local enhanced services for long-term conditions, devised by local clinicians. These provide an incentive to GPs to increase case finding for hypertension, diabetes, COPD and cardiovascular risk, and to improve their management of these conditions.
Clinical engagement is essential for advancing quality in primary care, but it can be a challenging process. The community of practice model is proving to be an effective way of achieving such engagement.
Promoting primary prevention
Lord Darzi's review rightly identifies that every healthcare opportunity is a health promotion opportunity. But there is a limited tradition of prevention in primary care. And in their busy consultations, GPs often lack appropriate tools and pathways to deliver primary prevention.
Using GP public health practitioners, Knowsley has tackled this by developing and implementing brief interventions on smoking cessation and physical activity (based on National Institute for Health and Clinical Excellence guidance); using the long-term condition local enhanced services to encourage case finding of people at high risk of CVD; and developing prevention pathways linking primary care with prevention services.
Building on experience in primary care and public health, the GP with a special interest in public health also supports local practice-based commissioning groups in their evolving commissioning role through:
commissioning for health and well-being;
integrating population thinking with individual patient thinking;
collaborating with non-healthcare sectors;
targeting health inequalities.
To deliver Lord Darzi's promise to improve quality, public health capacity in primary care will need to be substantially strengthened. The Knowsley example suggests there is much to be gained from building capacity in primary care. With expertise and credibility derived from both camps, GPs with a special interest in public health can provide the vision, advocacy and support for a more integrated primary care.