Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 104
Community Oriented
Primary Care:
An International
Perspective
Rodrigo G~errero
An attempt to describe the many projects related to community oriented
primary care (COPC) that are being or have been carried out around the
world is an impossible task, not only because of the immense number and
wide range of activities included, but also because of my limited knowledge
of them, particularly of those carried out in Africa and Asia. I have decided,
then, to restrict my discussion to two areas. First, I shall trace the origins
of the primary care, family medicine, and community medicine movements
in an effort tO better understand the scope and future of COPC. Secondly,
I will describe the COPC carried out in Cali that involves surgery and
surgical care, fields not very frequently concerned with primary care.
1
MOVEMENTS INFLUENCING COPC
Considerable confusion exists around the concept of primary care. To some
it means any health care given outside a hospital, given, as a rule, by a
general practitioner or a family medicine specialist. To others it means health
care of low complexity, regardless of the agent involved in the delivery of
care. Finally, others refer to primary care as the early contact at the home
level, frequently given by a nonprofessional in a continuous fashion to
defined population groups. In the British literature, for example, primary
care tends to be equated with the practice of the general practitioner.)
Much of the confusion, I believe, arises from three different movements—
family medicine, community medicine, and primary care that had different
origins but have at the present time very similar objectives.
104
OCR for page 105
An International Perspective
THE FAMILY MEDICINE MOVEMENT
105
The term general practitioner was introduced into the English language
around 150 years ago and referred to the way most physicians practiced
medicine in England. They were surgeons, obstetricians, and pediatricians
and they perscribed drugs.4 Later, with the development of the specialties,
the general practitioner almost disappeared. After World War II the term
general practitioner became popular as being the cornerstone of the English
National Health System. In 1957 John Hunt, one of the founders of the
Royal College of General Practitioners, referred to general practice as a
world movement, going beyond local health services and party politics
toward grouping family physicians. This movement recognized that modern
medicine, in order to reach maximal benefits, must reach patients early at
the home level and provide continuous care, including prevention of any
illness, mental or physical.5
In many countries, particularly the United States, the term "family med-
icine" was introduced to signify almost the same as general practice and
became very popular. The American Academy of Family Physicians is sec-
ond in number only to the American College of Physicians. In Latin Amer-
ican the Instituto Mexicano de Seguridad Social (IMSS) assumed a pi-
oneering role by adopting the scheme of family practitioners and introduced
in Latin America the concept and the term. The Seventh Panamerican
Conference of Medical Education in 1978 was devoted to the subject of
family medicine. Many countries of Latin America have had national meet-
ings devoted to family medicine. The World Organization of National
Colleges Academies and Academic Associations of General Practitioners
Family Physicians (WONCA) represented all the groups interested in the
area.
In the context of this movement primary care is synonymous with the
care given by the general practitioner or family medicine specialist. The
family medicine movement has been one answer to the health system crisis
of industrialized countries characterized by extreme, dehumanized, and
depersonalized health care.
THE COMMUNITY MEDICINE MOVEMENT
It can be said that the Flexner Report allowed science to be introduced in
medical education. However, the emphasis in the Flexnerian model was
the scientific study of the individual patient in a university hospital bed. A
number of years ago a growing concern about the social and psychological
demands of patients began to appear. The need to study the patient within
his social milieu began to influence medical education, and several com-
OCR for page 106
106
PART I THEORETICAL ISSUES
munity studies were undertaken by universities. The influence of.Tohn
Grant and his principles for community projects were important in shaping
this community medicine movement.
The leadership role of this movement has come primarily from the ac-
ademic community. Several American foundations, notably Rockefeller and
Kellogg, have contributed significantly to the development of this move-
ment, which was defined by Moshe Prywes as the "the First-born" of a
marriage between medical education and medical care.3 To the organizers
of this meeting COPC is an approach to health care delivery that undertakes
responsibility for the health of a defined population practiced by combining
epidemiologic study and social intervention with the clinical care of indi-
vidual patients, so that the primary care practice itself becomes a community
medicine program.2 A strikingly similar definition was given by Lathem
when he said: "Community Medicine is that branch of medical science
which is concerned with the health needs and conditions and with dealing
with these by appropriate methods and interventions, of population groups
of known size and composition."3 So, although having had predominantly
academic origins, the community medicine movement is actively contrib-
uting to improvements in the ways health services are provided to popu-
lations of the country or region.
Several of the better known projects have been projects in which univer-
sities have become involved in primary health care delivery. Lathem and
Newberry's edited volume describes some of these pro jects.6 A more recent
development has been the emerging of clinical epidemiology, which prob-
ably originated from community medicine, since it stresses the need for
clinicians to use sound epidemiologic criteria in order to make community
projects successful.
THE PRIMARY CARE MOVEMENT
In the developing world during the late sixties and seventies there was
increasing emphasis on more equitable health care distribution. Urbaniza-
tion, together with rapid demographic growth, generated enough political
pressure to force governments to study and implement strategies to increase
coverage of the health system. The 10-year plan for health in the Americas,
signed in 1972, is a typical example of the desire to increase coverage.7 In
1977 the Thirtieth World Health Assembly decided in Resolution WHA
30.43 that the main target of governments in the coming decades should
be "the attainment by all citizens of the world by the year 2,000 of a level
of health that will permit them to lead a socially and economically productive
life."9 According to Chavez this provided stimulus for the Primary Care
Movement that took a defined form under the leadership of the World
OCR for page 107
An l~ternation~l Perspective
107
Health Organization (WHO) and UNICEF in a meeting held at Alma-Ata,
U.S.S.R., in September 1978. A brief review of the recommendations of
Alma-Ata is pertinent to understand the meaning of primary care in this
context. According to the Alma-Ata Declaration, the following should be
included in primary care:
1. education concerning prevailing health problems and methods of pre-
venting and controlling them;
promotion of food supply and proper nutrition;
. an adequate supply of safe water and basic sanitation;
maternal and child health care, including family planning;
immunization against the major infectious diseases;
o. prevention and control of locally endemic diseases;
7. appropriate treatment of common diseases and injuries; and
8. provision of essential drugs.7
As defined at Alma-Ata primary care requires participation of the indi-
vidual and the community and can be delivered by health workers, profes-
sionals, nonprofessionals, technicians, and even empirical personnel. Alma-
Ata gave priority to the health agent or community health worker as a way
to reach people in dispersed rural areas or on the periphery of the big
metropolitan areas, where availability of health professionals is limited. It
was stressed that the training of physicians and nurses should include the
training and supervision of these health workers.
As can be seen from this brief summary, primary care, in the Alma-Ata
context, is a very ambitious program that involves systems such as education,
agriculture, housing, and public works. Since health is considered a basic
right of individuals, the definition of primary care becomes a strategy de-
signed to assure the fulfillment of this right. It is obvious that primary health
care in this context includes many activities not included in the primary
care as defined in the family medicine movement.
Primary health care as defined in Alma-Ata can be visualized in the form
of a pyramid. A wide base includes the many aspects of areas such as self-
care or care given by the family; a smaller intermediate section that cor-
responds to the care given by nonprofessionals, technicians, auxiliaries, etc.;
and the top of the pyramid, which corresponds to the small part of primary
care that requires professional care. On the other hand, as is frequently
done, health care can be classified according to the level of complexity. A
graphic representation would show a pyramid with a wide base of the many
low-complexity (primary care) problems, an intermediate section corre-
sponding to secondary care, and the top section, representing problems of
higher complexity or tertiary care. From an institutional point of view, the
OCR for page 108
108
PART I: THEORETICAL ISSUES
primary level corresponds to the health care, the secondary level to the
general hospital with the four basic specialties and high technology. Ac-
cording to this scheme, a physician working at the base should be called a
primary care physician regardless of the training. It is conceivable that
specialists such as pediatricians can work at the secondary level and still be
called primary care physicians. This often leads to confusion.
Much of the semantic discussion can be overcome by visualizing these
two pyramids (as in Figure 11. The top of the primary care pyramid im-
bricates into the base of the health care pyramid, indicating that the primary
care problems requiring professional attention belong to the low-complexity
section, and in few cases it may even belong to the secondary level. An
example could be the existence of hospital privileges for a general practi-
tioner in a general hospital.
This representation of the relationships of the two movements is taken
from the excellent book by Mario Chaves, Health, A Strategy for Change.8
It is obvious that the definition of primary care is closely bound to the
social and economic conditions of a country and the definition is relative
to the situation of health care. What constitutes primary care in a developed
country may be intermediate- or even high-complexity care in a less de-
veloped one. Given the wide diffusion and acceptance received by the
Alrna-Ata conference, I think the term primary care as defined by WHO
should be preserved. It is probably easier to abandon the classification of
/\
'W1
Highest
\ Intermediate
w ~ Low
Technicians, etc.
Self-Care, etc.
,, ~ ~ ,
J
| Primary
Health
Care
FIGURE 1 Relationship of two pyramids to explain the extension of the
primary health care concept.
OCR for page 109
An international Perspective
109
primary, secondary, and tertiary care and introduce the corresponding low,
intermediate, and high complexity of care. In the same way the practice of
a general practitioner in the English health system and the practice of a
family medicine specialist in the United States should not be called primary
care, but rather general practice or family medicine. By the same token,
pro jects related to the health of given populations or community medicine
projects need not have the term primary care included. It is understood
that the larger part of their efforts would be devoted to primary care, but,
certainly, all levels of complexity will be touched.
REFLECTIONS ABOUT COPC PROJECTS
EXTRACTED FROM THE CALI EXPERIENCE
In Colombia we started our first COPC project in 1958 in a rural town
near Cali, called Candelaria. The main purpose of the project was to have
a place where our graduates could make the compulsory rural internship
year useful. Very soon it attracted people from the social medicine and the
clinical departments and became our community laboratory. Although most
of the experiments do not meet the rigor of the experimental method, most
of them developed into experiences from which a great deal was learned.
Here I intend to summarize some of the wisdom gained in these years.
First, we found that COPC projects involve social change, and social
change takes time, even under favorable conditions. COPC projects have
a time span on the order of 10 years, sometimes more. No quick responses
are generally obtained from the community.
Second, COPC projects tend to function well at the beginning or in the
demonstration stage. One reason for this is the "Hawthorne effect," which
occurs because participants are actively interested in the good result of the
pro ject. Another reason is that the strong personality who generally initiates
such a project is exercising his influence. It follows then that COPC pro jects
should only be evaluated once they have reached a normal operation stage.
A third lesson is that, although primarily concerned with education,
universities and other academic institutions have something to learn from
the existing health system. COPC projects will always have some relation-
ship to secondary and tertiary care, if only to develop appropriate referral
systems. And, finally, stable financial bases are a key to the long-term success
of COPC projects. Grant or foundation monies given, as a rule, for short
periods of time may be used to start projects, but long-term support from
existing community institutions is needed. As a rule it iS better to "graft"
1 . · ~ · r
a project Into an existing Institution and assure its participation trom the
beginning in such a way that when the grant money is finished the existing
. . . . .
lnStltUtlOn W1] Continue.
OCR for page 110
110
AN INTERNATIONAL PERSPECTIVE ON COPC
PART ~ THEORETICAL ISSUES
The emergence of several independent movements with different origins,
in different parts of the world, and yet with strikingly similar objectives
points to recognition of the worldwide need for a COPC approach. As I
mentioned earlier there is a need, on the part of government agencies
(health ministries) of both developed and lesser developed countries, for a
means to increase coverage of health services and reduce costs. The Alma-
Ata mandate is compelling for less developed countries, yet, in affluent
countries like the United States, there continues to be a growing concern
about rising costs of medical care.
From an educational perspective there is a need to expose health profes-
sionals to COPC. This has taken two slightly different approaches. One
emphasizes clinical epidemiology. This approach has been sponsored most
notably in the United States by the Andrew W. Mellon Foundation and
the Milbank Memorial Fund. The aim of this movement is to introduce in
medical schools, and more specifically in the clinical departments, a more
quantitative approach to problems such as the prevalence and causal factors
of the more important diseases in the area. There has been some success
meeting this goal. McMaster University in Canada and the University of
Pennsylvania in the United States have assumed a training role for clinicians
of different countries.
The other educational approach tO exposing health professionals to COPC
has taken the form of a worldwide Network of Community Oriented Ed-
ucational Institutions for Health Sciences. Under the auspices of the World
Health Organization and support from the Rockefeller Foundation, several
educational institutions with innovative approaches to community oriented
medical education have organized a network with the primary objectives
being the interchange of experience in this area and help in the diffusion
of the concept. The University of Limburg, in Maastricht, the Netherlands,
has been appointed by the rest to act as secretariat for the group. In the
United States, Michigan State University and the University of Pennsylvania
belong tO the network, while the University of New Castle in Australia,
University of Tromso in Norway, Universidad Autonoma Metropolitana
of Xochimilco in Mexico, Universidad del Valle in Colombia, McMaster
in Canada, Ben Gurion University of Israel, and others from different parts
of the world make up the remainder of the group.
AN ATTEMPT TO IMPROVE THE SURGICAL CARE DELIVERY IN THE
CAUCA VALLEY
The following is an example of what could be called a community medicine
pro ject involving surgery, an area not frequently included in similar pro jects.
OCR for page 111
An International Perspective
111
Although it had its origin at the Universidad del Valle in Cali, Colombia,
after a succesful demonstration project, it has been officially adopted by
several cities and institutions in Colombia. Since it deals with low-complexity
procedures, it could also be called "surgical primary care," but, in accordance
with the previous considerations, we have not used that term.
The Department of Surgery of the Health Division of Universidad del
Valle undertook a large systematic study of the surgical care system of the
Cauca Valley, one of the geopolitical divisions of Colombia, with the pur-
pose of seeking ways to increase the coverage of the system. An inventory
of physical and surgical manpower resources was carried out. During 1 full
year all surgical interventions were studied and later were classified into
four different levels of complexity. An experimental surgical unit was or-
ganized in the university hospital, and a model of high productivity and
low cost for low-complexity operations was tested. After successful results,
the model was adopted by the city of Cali and several other cities of
Colombia. More detailed accounting of this study can be seen else-
where.~° ii The most striking results were:
1. Thirty-two percent of the existing 478 surgeons performed less than
one operation per week. The mean yearly productivity was 120 operations,
with striking differences with the specialties.
2. Of the 76 operating rooms, 46 were located in Cali, the capital city
of the Cauca Valley. Mean utilization of the operating rooms was 42 percent.
As a consequence, it was recommended (and accepted) that no new op-
erating rooms be constructed in the Cauca Valley.
3. Of the 50,782 surgical interventions carried out during calendar year
1974, three-fourths were of low levels of complexity and could be per-
formed on an ambulatory basis with immediate discharge after recovery
from anesthesia. Similar results were found in the United States using the
same classification of the interventions of low complexity.
4. Twenty-eight procedures make up nearly 90 percent of the low-com-
plexity operations, although they belong to different anatomical regions
and, consequently, to different specialties.
5. The cost of a herniorrhafy performed under the experimental model
was 530. (U.S. currency) in 1976. Under the traditional system, the cost
was five times higher.
6. Patient satisfaction and acceptance were excellent under the experi-
mental model.
Overall, this COPC demonstration project in the Cauca Valley has been
very successful and has been adopted elsewhere by other institutions in
Colombia.
OCR for page 112
112
REFERENCES
PART I: THEORETICAL ISSUES
1. Hicks, D. (1976) Primary Health Care: A Review. London: Her Majesty s Sta-
tionery Office.
2. National Academy of Sciences, Institute of Medicine (1981) Report of a meet-
ing of the Community Oriented Primary Care Planning Committee, Washing-
ton, D.C.
3. Lathem, W., ed. (1979) The Fature of Academic Community Medicine in Developing
Countries. New York: The Rockefeller Foundation.
4. Drury, M. (1976) Concepro y Evolucion de la Medicinal Paper presented at
the Simposio Internacional de Medicina General, Family y Comunitaria, Fa-
cultad de Medicina de la Universidad Autonoma de Mexico, Agosto 25-27.
5. HuntI.(1957)TheRena~ssanceofGeneralPractice.Br.Med.~.1:1075-82.
6. Lathem, W., and Newberry A., eds. (1970) Community Medicine: Teaching,
Research and Health Care. New York: Appleton-Century-Crofts.
7. Pan American Health Organization (1973) Ten Year Health PlanfortheAmericas.
Final Report of the III Special Meeting of Ministers of Health of the Americas
in Santiago, Chile, 2-9 October, 1972. Official Document No. 118. Washing-
ton, D.C.: Pan American Health Organization.
8. Chaves, M. (1982) Swede, Uma Estrategia de Mordancy. Editora Guanabara Dois
S.A. Rio de laneiro.
9. World Health Organization (1979) Formulating Strategies for Health for All by
the Year 2000. Document of the Executive Board. Geneva: World Health
Organization.
10. Velez, A., et al. Surgeons and Operating Rooms: Underutilized Resources.
Unpublished paper.
11. Velez, A., et al. Experiences in High Productivity, Low Cost Surgical Care
Unit. Unpublished paper.
Discussants
Stephen C. Joseph
I want to pick up on two themes followed by Dr. Guerrero, which are also
related to the papers of Drs. Abramson and Geiger. These themes are:
1. The problem of semantics, nomenclature, and jargon in defining what
we are about.
2. The importance of the existing worldwide network of those involved
in community oriented primary care, or whatever name may be the fashion
of the time or place.
OCR for page 113
An l~ternational Perspective 113
I do not mean to obscure the different emphases of the various labels.
Certainly COPC, as the newest term, has differences from community
health, community medicine, social medicine, primary care, comprehensive
health care, and so on. But, whatever labels we place on our efforts, we
are, all of us in this field, the professional offspring of John Granti and
Will Pickles,2 and our midwives are named Kark3 and Deuschle.4
COPC, in all its guises, has twin driving forces or underlying objectives.
These are access (sometimes called availability or entitlement; sometimes
expressed in terms of equity) and relevance, using epidemiology to show the
relationship between a community's highest priority health needs and the
deployment of resources to serve them. These twin objectives have been
present as part of COPC and related efforts both in the United States and
other affluent countries (with perhaps greater emphasis on access than on
relevance), and also in analogous activities in the developing countries (with
perhaps the emphasis reversed).
For example, there has been a heavy emphasis in U.S. COPC, as Tack
Geiger described in his paper, on "bringing the poor into the mainstream."
Most COPC activities in the developing countries have been trying to find
ways to stretch very scarce resources to cope with the most high-priority
problems (e.g., the development of village health workers, of essential drug
formularies, etc.) and have not had much hope of achieving universal or
even majority access for the mass of the population.
This was, of course, the great challenge of Alma-Ata, and the greatest
excitement of having been there was to see the world health community
take up the ideal of fusing the twin objectives of access and relevance as
the main means of improving world health, as applicable in Boston as in
Bombay or Bogota.5
While my remarks today are concerned more with the organization and
delivery of services, let me at least mention that these twin concepts of
access (I will use the word equity from here OUt) and relevance need also
tO be embedded in COPC efforts in medical and other health professional
education.6
When preparing my remarks, I thought for a time of taking a small sample
of this group gathered here at Airlie House, a sample at various ages and
career stages, and plotting, or at least calculating, the number of significant
prior professional interactions among the sample. In the end, I decided not
to; however, I hope you will accept my point in anecdotal form; we are
possessed of a worldwide and unusually interconnected network. This net-
work gives us both resiliency and continuity when, in a given period in a
given country, we find ourselves in hard times and in a political and eco-
nomic climate hostile to our COPC aspirations. This is clearly the case at
present in our own United States. Our COPC international network (though
OCR for page 114
114
PART I: THEORETICAL ISSUES
no one would recognize it by that name) is characterized by slow but
evolutionary progress and has taken root and spread almost everywhere
that I can think of, and certainly in every country that I have seen, in the
past few decades. It is the existence of this network that leaves me less
pessimistic for developments in my own country, not that I would urge
complacency or less than full-scale criticism of policies that work against
equity or relevance, anywhere. But I am confident that our dispersed efforts
have a great survival value, that they will continue to gain in impact and
momentum, and that we will, all of us, continue to borrow seeds and grains
from far places with which to cultivate our own gardens.
COPC has been the most international in all of medicine; it is also
important to note that it has proceeded by a process of evolution rather
than by quantum revolutionary research advances. These two characteristics
have meant that our field shows major local variation in adaptation and
coloration and that most of the major tools have been discovered and
rediscovered many times. However, in all our diverse settings, whether in
affluent or poverty communities, three principles have generally been con-
sidered as defining COPC. I want to add a fourth "pillar" to our list, not
because I think it has not been thought of before (on the contrary, it is
almost always an integral part of any program of COPC), but the fourth
element often is left Out of the formal listing. The first three pillars are, of
course:
1. The care of a defined population or community, with the full and
active involvement of that community.
2. The linkage between clinical care and preventive, promotive, and
public health services, utilizing a multidisciplinary health care team.
3. Adding the tools of epidemiology and the behavioral sciences to the
physician's bag.
The fourth pillar of COPC, which I will amplify later, might best be termed:
4. Social and political activism aimed at the root causes of illness and
wellness.
Many years ago, Virchow said that "Politics is medicine writ large." We
have learned from the international context, and especially from the trans-
national context, that the converse is also true. One need only think of
recent international controversies over the promotion and marketing of
infant formula, or over the export and use of banned pesticides, or over
the behavior of the multinational pharmaceutical industry, to see very sharp
and important examples of how larger political and economic issues affect,
OCR for page 115
An International Perspective
115
not just health in the abstract, but community oriented primary health care,
all the way from the health environment of the denominator community,
to the costs and benefits of organized services, right down to the clinical
primary care of individual patients.
In the history of COPC development, one does not have to look at
international issues to track the attention paid to underlying political, social,
and economic issues. Back in the days of the Office of Economic Oppor-
tunity's Neighborhood Health Center Program, I remember food produc-
tion cooperatives in Mississippi, lawyers in health centers working on such
issues as lead paint in New York City, and a variety of other direct social
and political initiatives that were at the heart of what that program was all
about. This social activism in the cause of COPC is, I submit, as important
as the other three central principles.
I end up, then, with four pillars in my definition of COPC. That definition
can be, and has been applied in, settings as widespread as Watts, Wales,
and West Africa. This array of international perspectives, at once similar
and yet diverse, from which we continue to learn from each other is the
proof of our relevance and also our greatest strength.
REFERENCES
Siepp, C. (1963) Health Care for the Community: The Collected Papers of fold B.
Grant. Baltimore: Tohn Hopkins Press.
2. Pickles, W.N. (1939) Epidemiology in Country Practice. Bristol:.Tohn Wright.
3. Kark, S.L., and Steuart, G.W. (1962) A Practice of Social Medicine. Edinburgh:
. .
Llvlngston.
4. Adam, T., and Deuschle, K.W. (1970) The People's Health: Anthropology and
Medicine in a Navajo Community. New York, Appleton-Century-Crofts.
5. World Health Organization (1978) Report of the International Conference on
Primary Health Care at Alma-Ata, U.S.S.R., 6-12 September, Geneva.
6. Toseph, S.C. (1978) Education for Health: The Gap Between the Hospital and
the Community. World Hosp. 14(February).
Keith Bolder
Dr. Guerrero has mentioned the virtual disappearance of the general prac-
titioner earlier in this century. This, of course, was true in America, but in
the United Kingdom there never was any question of the general practi-
tioner disappearing. Indeed, since 1911 the health care system has been
structured on this very person, and the 1948 National Health Service Act
only reaffirmed this point of view. There are a great many assets for patients
in having personal and continuing care from one clearly identified family
OCR for page 116
116
PART I: THEORETICAL ISSUES
doctor. This has always been possible within our system, because patients
have to access all health care through their family doctor.
My colleague in Exeter, Dr. Dennis Gray, classified general practitioner
care into six components. These are primary care, family care, domiciliary
care, preventive care, continuous care, and holistic care. Dr. Guerrero
defined primary care, and it has been covered elsewhere in these proceed-
ings and on many other occasions. Family care is very clearly described and
documented with its virtues by Huygens in his classic book from the Neth-
erlands on family medicine. Domiciliary care and the value of seeing the
patient in his own home has been clearly shown by Dennis Gray in his
lames McKenzie lecture to the Royal College of General Practitioners in
1977.
Preventive care and the important role that the family doctor has to play
in this has been clearly identified in the recent Royal College of General
Practitioners publication by a working party on this subject. A marvelous
example of preventive care is given in this document. It outlines two Ni-
gerian villages that were studied by this group. They looked at the under-
five clinic that had been established in the village. This clinic combined
preventive and curative services on a daily basis. It was staffed by two nurses
and six midwives and dealt with 41,000 visits by under-fives each year. In
the neighboring comparison village, there was a local dispensary employing
one dispenser and two midwives. It dealt with 3,700 child welfare visits in
a year.
The difference in under-five mortality between the two villages was
striking and cannot be accounted for by any factor other than health inputs.
For example, infant deaths were halved, and child mortality rates in the
study village were a third of that in the other village, with a significant
growth difference between the children in the two villages. Ninety-nine
percent of the study children had vaccinations and only 45 percent in the
other village. As can be seen from this simple example in primitive con-
ditions, a great deal can be done with preventive care.
Computerization was mentioned in an earlier paper, and for the past 7
years I have been involved in the Exeter computer project. This project
was originally conceived as a means of computerizing the whole of the
health care area both the hospital and the community aspects of it. Un-
fortunately, over the years, with the steady restriction of funds the original
framework has had to be modified, but, nevertheless, this project is still
running, and computerization of a community is possible.
Great interest has been shown in the use of computerization in primary
care in Britain, and various ways of implementing this for the benefit of
the community are being explored. Major epidemiologic and preventive
care advantages to the community will result from computerization of clin-
OCR for page 117
An l~ternational Perspective
117
ical records, which will enable such information as the incidence of hyper-
tension and diabetes to be recorded or the identification of at-risk groups
for various preventive activities such as immunization or cervical smears.
The conclusion of this important report places the responsibility for
preventive care firmly in the lap of the general practitioner as a coordinator
of these activities within his practice. It was interesting to me that Dr.
Guerrero was making a claim for the universities to be responsible for this
particular field. However, the implications of this general practitioner re-
sponsibility are that the family doctor must have the resources to accept it,
and he must have efficient record and recall systems and the full cooperation
of the primary health care team.
Finally, we come to continuous and holistic care. The Leeuwenhorst
Working Party in 1977 defined the general practitioner as a doctor who
provides personal, primary, and continuing care. If the doctor, seen by the
patient on each occasion, is different, the many advantages of continuous
care are lost. The Leeuwenhorst job definition states that the doctor should
have empathy with the patient and should use the therapeutic relationship
that develops over a period of time for the benefit of that patient. The
implication of this is that the patient needs to see the same doctor on more
than one occasion, if that doctor is to become his personal doctor.
Working together with the personal care of the doctor is the practice
team and the members of this team, who include the secretaries and re-
ception staff, the nurses, and the community workers such as health visitors
and midwives. These members should also offer personal and continuing
care so that they all work together on a personal and continuing basis to
complete the concept of COPC.
Given this emphasis, there is then the matter of training this team. Vo-
cational training for general practice in the United Kingdom has developed
rapidly in the past 10 years, culminating in the Vocational Training Act of
1981, which firmly puts the general practitioner on an equal postgraduate
training footing with a specialist in a hospital. There are many schemes
producing highly trained young doctors to enter general practice. These
doctors, besides being trained in the well-recognized fields of clinical knowl-
edge, also include in their training other aspects, such as behavioral patterns,
practice organization, and the implementation of principles of preventive
care within the population for whom they are responsible.
All patients, as I have said, have access to health care through their general
practitioners, and it therefore makes it much easier to implement policies
of care related to the community the practitioners serve. Alongside the
training of family doctors are parallel developments for the other members
of the primary health care team. The Royal College of General Practitioners
and the Association of Medical Secretaries have long recognized the ne-
OCR for page 118
118
PART I: THEORETICAL ISSUES
cessity of a training program for reception staff. Health visitors have to
undergo extensive training, including a 1-year, full-time course. At present,
I am in a working party with the Royal College of Nurses developing
postgraduate training for practice nurses. In addition, there have been some
experimental courses such as the one we are running at Exeter. This is a
course that has been run on a research basis to look at the ways in which
one might train members of the remedial professions on a postgraduate
basis. It has proved to be a highly popular course and is giving these people
postgraduate support from their peers, which they have never had before.
Now, finally, what about the patient? Patient satisfaction studies in the
United Kingdom still show that most patients think highly of their family
doctor. However, there are indications that all is not as satisfactory in this
area as one might wish, and those complaints can be traced to situations
where the practice was not organized on the basis of pesonal care. A recent
trend has been the establishment of patient participation groups described
in another report fom the Royal College of General Practitioners, and I
am sure that this liaison between the health care professionals and the
patients can only be good and will expand.
Indeed, I think the challenge of this decade is to involve the patient in
his or her own health care, and this, in fact, seems to me to be the basis
and cornerstone of COPC.
Representative terms from entire chapter:
family medicine
