Medical audit has become an accepted part of clinical ... vide skilled pre-hospital care at road accidents and medical ..... Scottish Medical Journal 38, 79-80.
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CHAPTER 5
Balancing proactive and reactive care John CM Gillies FRCPEd, MRCGP, A Gordon Baird MRCOG, MRCGP, and E Mary Gillies MRCP "Choice implies sacrifice." Soren Kierkegaard 1813-55. "Nature cannot be ordered about, except by obeying her." Francis Bacon 1561-1626.
THE last five years have seen major changes in general practice. These include the 1990 contract (Secretaries of State for Health, 1989), Care in the Community (Department of Health, 1990) and the Patient's Charter (Department of Health, 1991). The purchaser-provider split has fundamentally altered the role of general practice and general practitioner fundholding, locality commissioning and primary care strategies have brought responsibilities and increased workload for those involved (Howie et al., 1992; Scaife, 1993). Computers in the consulting room are now the norm. Medical audit has become an accepted part of clinical management. Guidelines have appeared on asthma, diabetes, hypertension and heart failure (British Diabetic Association, 1993; British Thoracic Society et al., 1993; WHO/ISH Mild Hypertension Liaison Committee, 1993; McMurray and Dargie, 1994). Thrombolysis has revolutionized the management of acute myocardial infarction and general practitioner involvement in pre-hospital care (Cobbe, 1994; Hannaford and Waine, 1994; Weston et al., 1994) and in community hospitals (Gordon, 1989) it is an accepted part of management (see also Chapter 10). The Health of the Nation strategy (Secretary of State for Health, 1992) involves general practitioners in very ambitious targets for improving the health of practice communities. Forthcoming changes will include quality assurance (Grol et al., 1993). Given this deluge of change, it is not surprising that workload has increased and morale has fallen (Sutherland and Cooper, 1992; Bogle, 1994), that recruitment is in crisis (Thistlewaite, 1994; see Chapter 13), and that the past Honorary Secretary of the Royal College of General Practitioners has despaired of general practice being treated as the 'elastic dustbin' of the NHS (McBride, 1994). Given that time itself is not elastic, general practitioners and primary care teams must be increasingly efficient in organizing their work. Kierkegaard's aphorism that choice implies sacrifice, while apparently self-evident, sits ill with a burgeoning workload and a commitment to quality of care. Britain spends less money on health than many other European nations (Ham et al., 1990). This relative lack of resources makes it imperative that what resources there are should be used to best effect. The history of medicine is littered with unsuccessful, wasteful and dangerous treatments from clysters (enemas) to clofibrate and doctors have a duty to their patients, themselves and the taxpayer to minimize these in the future.
The increased emphasis on proactive care (health promotion) in the 1990 contract has caused especial difficulties for rural practice. Rural general practitioners are at a distance from casualty departments, district and maternity hospitals and hospices. Deputizing services do not exist and duty rosters are often heavy. This means that rural practitioners must focus on acute reactive care which often can not be delegated. This paper looks at both reactive and proactive care and tries to assess what is effective, what may be useful, and what is a waste of time.
Reactive care Spence (1960) has defined the consultation as follows: "The essential unit of medical practice is the occasion when, in the intimacy of the consulting room, a person who is ill, or who believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation, and all else in medicine derives from it." This definition has not been bettered and accurately describes reactive care. Listening and offering appropriate treatment and advice is still the primary role of the general practitioner today and is perceived as such by the public. It is entirely compatible with high quality modern primary care and comprises the bulk of general practitioner workload. Personal lists, the norm in rural practice, can reduce consultations for minor self-limiting illness (Pereira Gray, 1979). A recent survey suggested that choice of general practitioner was less important to many patients than continuity of care by a single general practitioner (Freeman and Richards, 1993). Acute care In rural areas, general practitioners are often involved in emergency pre-hospital care, as accident and emergency units may be too distant for self-referral. Many rural surgeries and community hospitals have functioned as de facto primary care emergency centres for many years and deal routinely with suturing, ocular foreign bodies and other
minor injuries. The British Association for Immediate Care (BASICS) exists to support and encourage doctors to provide skilled pre-hospital care at road accidents and medical emergencies. Many rural general practitioners participate in the 73 BASICS schemes in the UK (BASICS, 1992). There is an encouraging trend for those taking part in such schemes to undergo Advanced Trauma Life Support (ATLS) training
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(Anderson I, personal communication) and there is now excellent evidence that ATLS techniques applied in the first hour after injury to trauma victims can prevent death and reduce disability (Alexander and Proctor, 1993). Acute myocardial infarction is a life-threatening emergency, particularly common in Scotland (Kendell, 1994). A rapid response with analgesia (not currently provided by all paramedics) and definitive treatment are essential. Defibrillation by general practitioners can lead to long-term survival (Macdonald et al., 1993). The GREAT trial showed conclusively that pre-hospital thrombolysis given by general practitioners was safe, and reduced mortality (GREAT Group, 1992). British Heart Foundation guidelines suggest that the aim should be to give thrombolysis in acute myocardial infarction within 90 minutes (Weston et al., 1994). This is a challenge which can only be met in some rural areas by general practitioners and is being actively addressed in Galloway (MacDonald J, personal communication). Thrombolysis can also safely be administered in community hospitals staffed by general practitioners (Gordon, 1989). This is a good example of acute reactive care which is of proven value to the patient and rewarding for the general practitioner, but requires time and a rapid response. Intrapartum obstetrics is another feature of rural practice that is greatly appreciated by patients and their families. Transporting women in labour over long distances in bad weather adds substantially to the risk for mother, baby, staff and relatives. As Baird and Gillies discuss in Chapter 7, evidence is accumulating that maternity units run by general practitioners are as safe for selected low-risk mothers as consultant units (Jewell et al., 1992). However, learning and maintaining skills required for acute care, such as ATLS, Advanced Cardiac Life Support, BASICS and obstetric training, require residential courses which take doctors away from their practices.
Continuing care Care of patients with conditions such as asthma, diabetes, angina, chronic heart failure and chronic obstructive airways disease embraces both reactive and proactive elements, but is rooted in reactive care. Guidelines such as those from the British Diabetic Association (1993), the British Thoracic Society et al. (1993), the WHO/ISH Mild Hypertension Liaison Committee (1993), and McMurray et al. (1994) are useful in achieving high quality care especially when these can be applied and if necessary, modified by a general practitioner who knows the patient well (Delamothe, 1993). Control of all of these conditions can be improved by modification of patient behaviour and lifestyle and it is the general practitioner's responsibility to make his patients aware of the importance of smoking cessation, control of alcohol consumption, diet and exercise. However, advice given opportunistically, especially when related to an underlying medical problem like diabetes, angina or asthma, is likely to be more effective than unsolicited advice given to a well person which may be perceived as gratuitous and rejected (Rollnick et al., 1993; Stott, 1994). Because rural general practitioners often live in small communities with their patients, they have a knowledge of them from outwith as well as within the consulting room. This can mean more honest consultations and consequently more effective advice. It is also important to remain aware of the complexity of
the consultation and to ensure that hidden agenda are explored when appropriate (Neighbour, 1987). An appealing but Utopian editorial on the future general practitioner (Pereira Gray et al., 1994) suggests that computers can be used to take the drudgery out of doctoring by allowing the general practitioner access to accurate information on his patients' past illnesses, chronic diseases and lifestyle. This potential is already being realized, but it should be remembered that in the consulting room, the impact of the computer on doctor-patient interactions has not been fully assessed. There is a danger that the problems and concerns of the patient will be addressed less enthusiastically than risk factors which are flashed on to the screen during the consultation and compete with the patient for the interest of the doctor. Choice implies sacrifice, even when the choice is unconsciously made. There is evidence that eye contact, an important marker of a therapeutic doctor-patient relationship, is reduced in consultations with a computer present (Campion, 1993). The provision of high quality care of the dying is very important. A recent audit suggested that in rural practice 64% of patients die under general practitioner care, compared to 35% in urban areas (Gillies, 1993). Of 30 deaths from cancer in this study, 12 took place at home and six in a general practitioner hospital. The remaining 12 patients died in a hospice or district general hospital 75 miles from the practice. Development of an outreach team and local clinics from the hospice enhanced the service and increased the numbers of patients receiving palliative care from the general practitioner-based team. Geography therefore dictates a higher input of general practitioner time in this intensely rewarding area of practice, where reactive care is of the essence.
Proactive care Proactive care can be defined as care in which the doctor attempts to prevent illness by intervention in asymptomatic individuals. Proactive care has a different ethical basis from reactive care in that it is initiated by the doctor rather than the patient. It is therefore important to ensure that the principle of primum non nocere is observed. It is important to acknowledge that social and environmental factors play a larger role in health than the advice of health professionals (Fowler et al., 1993). The lamentable failure of the government to ban tobacco advertising, ignoring evidence that consumption would be reduced (Department of Health Economics, 1992), is a good example of a missed political opportunity to improve the health of the nation. Is proactive care effective? Childhood immunization, including the new Hib vaccine (Chief Medical Officer, 1994), is extremely effective, although targets may not reduce social inequalities in uptake (Reading et al., 1994). Evidence is accruing that cervical screening saves lives (Macgregor et al., 1994). Screening and treatment for high blood pressure can prevent stroke and heart failure (Medical Research Council, 1992; Fowler et al., 1993). There are fewer data to support child health surveillance (Hall, 1993; Audit Commission, 1994), although the new system represents an improvement on the chaos that it replaced. Debate continues on screening the elderly (Iliffe, 1992), although survey evidence suggests that practice teams may find it useful (Chew et al., 1994).
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On the downside, three-yearly checks have been abandoned after being found valueless (Noakes, 1991). Routine urinalysis for urine sugar produces negligible yields in the under 60s. Screening for blood in the urine has a high false positive rate and results in over-investigation (Mant, 1993). New patient screening is useful for introducing the patient to the practice and vice versa, but may be most used by those in least need of help (Griffiths et al., 1994). With the advent of Health of the Nation targets and health promotion banding, screening and intervention for cardiovascular risk factors has become an important part of practice activity. It has been implemented nationally without any sound evidence of efficacy (Kelly and Charlton, 1992). The OXCHECK and Family Heart Studies (Family Heart Study Group, 1994; Imperial Cancer Research Fund, 1994; Stott, 1994) have shown that such methods achieve no definite health gain. As McCormick (1994) points out, the ethics of an intervention that labels 79% of those studied 'unhealthy' while offering them nothing in return must be questioned. Psychological distress may be caused (Stoate, 1989) and Noakes (1994) has questioned the point of the system. Huge amounts of patient time and NHS resources have been wasted in this process. This approach probably fails because of a simplistic belief in the ease of behaviour change (Rollnick et al., 1993) and because it is not orientated to the perspective of the individual (Kelly, 1992; Kelly and Charlton, 1992). A general practitioner who knows his or her patients well can combine reactive care with well-timed opportunistic health promotion to good effect, as in smoking cessation (Russell et al., 1979; Austoker et al., 1994) and alcohol problems (Anderson, 1993; Austoker, 1994). Conclusion Acute reactive care is an important component of rural practice. It commands priority over all else and often cannot be delegated. Management of acute emergencies such as acute myocardial infarction and major trauma by rural general practitioners is effective. Geography dictates that continuing care of patients with chronic and terminal illness is inevitably undertaken by the primary health care team in rural areas. The only worthwhile proactive care is that which has been proven effective by careful medical research, for example, immunization, cervical screening and treatment of hypertension. In contrast, current national attempts to change lifestyle and alter cardiovascular risk factors in the form of the health promotion regulations have been heavily criticized on ethical and theoretical grounds (Kelly and Charlton, 1992; Rollnick et al., 1993). Research suggests that they will not achieve health gain (Family Heart Study Group, 1994; Imperial Cancer Research Fund, 1994). They have caused a diversion of resources away from effective strategies and should be rapidly amended or abandoned. It is dispiriting for general practitioners and their teams to have to continue to implement policies of proven futility. Four hundred years ago, Bacon (1561-1626) pointed out that nature can only be ordered about by obeying her, in other words that actions, to be effective, must be based on the results of careful observation. The primary task of general practitioners is to listen, elicit and react to the patient's agenda. However, the advent of
consulting room computers means that attention can all too easily be diverted to data collection and the proffering of unsolicited, unproductive advice. There is a risk of moving away from listening and responding to talking and telling. As a result of health promotion and Health of the Nation targets, an unacknowledged tension has arisen in general practice between treating individuals and attempting to improve the health of population, in other words between reactive and proactive care. The current balance between these is distorted by contractual obligation towards ineffective proactive care. This subject deserves further debate within the College, the profession as a whole, the Department of Health and the general public.
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