Chris van Weel
Keynote Lecture
KL 2 / Three of a kind? Patients, General Practitioners and Community Pharmacists
Key note address for the conference on
Health Promotion in General Practice and Community Pharmacy: Experiences and Perspectives, 10-11 November 2000, Brussels

Abstract

This presentation reviews the role of general practice in health promotion and education in relation to the specific task in health care. From this, the interface between general practice and community pharmacy is defined.

General practice combines the competence of the medical generalist and the personal doctor. Empowering patients is an important ‘intervention strategy’ where health education is used. But it is important to acknowledge that this is directed at individual patients, within a personal bond between GP and patient. Health promotion is by and large driven by the opportunities that present themselves during individual encounters, and are common interventions alongside other interventions. This should be recognised in guidelines and other projects that further general practice development.

The interface between public and individual education is important, as the most powerful information is provided when individual advice is backed up by a public health message. A stronger evidence-base of its effectiveness is needed. But health promotion research must take place in the context of general practice care.

Co-operation between general practice and community pharmacy should focus on the specific expertise of the two disciplines and relate to drugs and medication use by individual patients. GPs and CPs complement expertise on illness and disease versus quality and appropriateness of (self) medication. This can be used to promote ‘compliance’. Protection of patients can be enhanced by the discouragement of the inappropriate use of drugs, and by monitoring of adverse effects. Given the complementary expertise of GPs and CPs, job-competition should be prevented. This conference offers a perfect opportunity to demonstrate the potential of GP-CP co-operation.

Introduction: the challenge

The potential of health care is ever expanding and as a consequence, there is increasing concern whether actual care is meeting its potential. Two factors re-enforce these concerns: the increase of health care-related costs and the fact that medical care can be harmful as well as beneficial for patients. As a consequence, there is a strong need to tune medical care to the needs and expectations of individual patients. Primary care is generally seen as a way to achieve this: the provision of care at reasonable costs, in the context of the local community where patients live. The development of high quality primary care is one of the cornerstones in the reshaping of the health care structure of many (European) countries.

A number of professionals have their working place in the community :
- General practitioners/family physicians
- Physiotherapists
- Community Nurses
- Social workers
- Midwifes
- Community Pharmacists

General practitioners and community pharmacists have a number of characteristics in common: their services are directly available and their services are directed at unselected health problems. This presents in itself interesting conditions for health promotion and health education. Drugs play an important role in the treatment of ill health; both in professional care and in lay- and self-care. There are, however, grave concerns with regards to the over-reliance on, and inappropriate use of, drugs. The negative implications of the large-scale use of antibiotics, analgesics and tranquillisers, for example, are widely documented, and this signals the need of consumer protection. As a consequence, there is an interface between general practitioners and community pharmacists in the promotion of rational pharmacological practice.

The aim of this presentation is to:
- review the role of general practice in health promotion and education;
- the strengths and weaknesses in relation to the specific task in health care;
- the interface between general practice and community pharmacy in this;
- the role of the community pharmacist – from a general practice perspective.

General Practice

General practice is the medical care professional discipline of primary care, a medical speciality. General practitioners (GPs) provide medical care for patients throughout the European community, but the regulations and conditions under which patients can access care differ from country to country. However, two general systems can be distinguished(1):
- a system organising access to care through general practice (“primary care system”);
- a system where patients have a choice between GPs and other specialists to consult (“competition system”).

These differences should not disguise that there is a strong common ground in the content of general practice care, summarised in figure 1.


Irrespective of the system under which they work, GPs treat unselected health problems and are the professionals responsible for the majority of illness in the community, leaving only a small quantity for (hospital based) specialists. From this follows the common clinical basis of general practice(2)(figure 2)

.

The competence of general practice
General practice combines (3) the competence of the medical generalist:
- are for all, unselected health problems in all patient groups;
- early signs/symptoms;
- combining cure, care and prevention;
- emphasis on effective and efficient diagnostic and therapeutic interventions

with features of the personal doctor:
- continuity of care;
- family medicine;
- patients’ expectations;
- empowering individual health and strength (health promotion);
- addressing individual, social and cultural norms and values.

The professional development of general practice is based on the exploration of these elements in a comprehensive way. This in all probability makes an essential contribution to the overall effectiveness of health care(3)(4). The implications for health promotion are important to take into account, though. Health promotion in the context of general practice is part of the individual care of patients – not a ‘stand-alone’ project or a special interest activity. The personal dimension of the GP – patient relationship can provide professional reasons to modify or even delete ‘educational’ points. To illustrate this with a simple example: smoking cessation is an undisputed target of health promotion. For the GP, the issue is not to campaign for it, but to look for opportunities in the encounters with individual patients to address it. And in some cases where patients have decided to continue smoking despite the advice received, it might even be best to refrain from further addressing this point. It is better to safeguard a working relationship with the individual, than to be right but to have lost the patient (or the patient’s goodwill).

General practice, scientific evidence and the specialty of primary care

Evidence-based medicine has resulted in a better understanding of general practice’s role in health care, and the development of evidence-based guidelines has facilitated the exchange of expertise. This has contributed to the quality of care, and research in general practice is a priority in order to build the evidence base. But at the same time, it is important to define the evidence that is needed to enhance further the quality of general practice. Given the dual orientation on common illness and patient-related domains(5), clinical research must encompass both in an integrating way. The implication of this is larger than it may seem at first sight, as it redirects the research agenda from a disease orientation to the humanities of medical care, and requires academic general practice leadership. This is in essence summarises the specific expertise of the general practice and defines where general practice is special: the speciality of primary care(6).

Though the practice is general - in terms of access of unselected and undifferentiated health problems, the skills of the practitioner has to be highly sophisticated. Figure 3(7) compares the ‘generalist’ and the ‘specialist’ and from it can be concluded that both are particularly adapted to the environment they serve: the complexity of body- and organ systems in case of the hospital specialist, the contextual complexity of the specialist of primary care.


From this I challenge you with three conclusions:

I. On General practice and health education
- Empowering patients is an important ‘intervention strategy’ in general practice.
- Health education in general practice is, in particular individual health education, where the personal bond between GP and patient plays an essential role.
- Health education is a common intervention strategy and study of its effectiveness is essential for the development of evidence-based general practice.
- Health education is by and large driven by the opportunities that come from the GP – patient encounter.

This should be recognised in guidelines, educational targets and any other projects that further general practice development.

II. On the Strength and Weakness of Health Education in General Practice
- GPs should concentrate on education of individual patients, in the context of the time and circumstances of consulting, rather than on ‘public’ campaigns
- Health education requires an interface between public and individual education
- Development of effective techniques must be pursued by individual education in the context of a consultation.
- The evidence-base of individual education in the context of a consultation must be enlarged.

This should be a priority of research and development, but importantly, of research in the context of general practice care, and not with a perspective of stand-alone single issue campaigns.

III. On The Interface between General Practice and Community Pharmacy
- GP - CP co-operation should concentrate on drugs-related issues.
- The basis for GP – CP co-operation: complementary expertise

- GP as the expert on signs/symptoms and illness & disease - CP as the expert on quality and appropriateness of (self) medication

- supervision of ‘compliance’: to make happen what is possible
- emphasis on discouraging inappropriate use of drugs
antibiotics, analgesics, tranquillisers
- techniques of medication
- monitoring of adverse effects
- prevent job-competition: health care is no market

This is in my view the most critical issue. GPs and CPs should first decide on their professional priorities, before the topic of health promotion can be discussed with success. Competition in the health market offers the short term attractions of commercial success. I hope the long term objective of high quality patient care will prevail, and this conference offers a perfect opportunity to further this aim. The master demonstrates his skills through his limitations– and I challenge GPs and CPs to use this meeting to demonstrate our professional priorities, and with it our limits.