Little Sick Big Sick (why GPs have one role in Primary Care, and Pharmacies have another)

GPs and Pharmacies have roles in primary care – but it’s not either or. It’s both. They shouldn’t be competing against each other.


Professor Jackson has her views and expresses them eloquently below. My views are:


GPs provide excellent care and deliver fantastic value to their patients and to Australia.

Other health practitioners also have the potential to provide excellent care to people. They may very well provide care to many many people that GPs don’t already see!



Let’s look at some communities and people that aren’t well looked after under the current system like ATSIs, people with an intellectual or physical disability, the homeless, and the poor.


Have I forgotten anyone?


Can we do better?

Tell me below!

(from Professor Jackson, Australian Doctor 2009)
IT’S as pervasive and globally contagious as swine flu — and potentially as deadly in a susceptible population.
I am talking about the growing conventional wisdom that general practice is a basic combination of lots and lots of ‘little sick’ (so much more easily and less wastefully dealt with by nurses) and the far less frequent ‘BIG SICK’ (which requires the calling forth from the back room of the big gun, highly-trained, clever-dick, scarce-in-supply GP).
Such wisdom has led to the situation in the UK where nurse-led clinics in hypertension, asthma, lipid management, COPD, diabetes, and so on are increasingly the order of the day. In this utopian setting, issues of patient concern are dismembered carefully into presenting ‘body parts’, where nurse-led protocols can be used to define management algorithms. The GPs remain available for those patients who defy the guideline, or where the nurse perceives they require professional referral.
Naturally, there are quite a few problems with this approach, particularly for a country that leads the WHO/OECD league tables for longevity, patient GP satisfaction, and preventable death rates.

The first problem is this myth is based on a totally flawed assumption. The ill-defined nature of primary care presentations makes accurate diagnosis and problem definition the most challenging of all medical specialties. GPs and practice nurses are greatly offended by the oft-heard view that general practice is mostly ‘vaccinations, coughs and colds and protocol-driven chronic disease management’.
When is ‘diarrhoea’ due to viral infection, and when to coeliac disease, alcoholism or rectal cancer? When is ‘cough’ due to parvovirus rather than oesophageal disease, anxiety, sarcoid or lung cancer? When is ‘nausea’ viral and when secondary to polypharmacy, renal dysfunction, drug abuse, cholecystitis, depression or Barrett’s oesophagitis?
The skill involved in accurately and rapidly diagnosing problems in general practice is profound, requires complex clinical reasoning, and a significant skill base. It is entirely inappropriate to triage most primary care patients into anatomical group assessment clinics based on presenting complaints. To do so is to risk diagnostic delay, confusion and inconvenience for the patient and often significant expense.
Patients deserve and expect the best qualified person to work with them in the all-important problem definition and initial management decisions. In our world, that is the GP/practice nurse team in combination.
The second problem with the myth of little sick/big sick is the absence of any pretence at patient-centredness.
What patient wants to book appointments at predetermined clinic days/times for between one and four separate comorbidities? How do they fit that easily with competing demands from work, family and carer needs?
Third, the myth ignores the significant and growing prevalence of comorbidity in primary care.
Recent data has charted the growing increase in disease co-morbidity in our communities. Such presentations predicate a skilled generalist approach. General practice is trained and skilled for this and is increasing its capacity to deliver.
Fourth, the myth contributes to the decimation of continuity of care.
Stephen Campbell’s paper in the New England Journal of Medicine
in July this year chillingly chronicled the demise of continuity of care in UK general practice since the 2003 reforms. Such data allows Australian communities, governments and health professionals a sneak peek at the consequences if we emulate this model.
The fifth problem in this myth is the complete antithesis of the consultation and reform agenda advanced by the National Health and Hospitals Reform Commission and National Primary Care Strategy. Throughout the reform process, consumer groups overwhelmingly said they wanted comprehensive, co-ordinated, integrated, patient-centred care delivered to themselves and their families — not a fragmented ‘little sick/big sick’ approach.
Finally, there is no evidence for enhanced benefit.
The Cochrane Collaboration summary on the equivalence of GP-led and nurse-led care has more disclaimers than a set of K-Tel steak knives. Most damning is the statement that these findings “should be viewed with caution given that only one study was powered to assess equivalence of care, and many studies had methodological limitations”.
So, Australian policy-makers, reformers and governments beware — 50 years of general practice hard slog has resulted in international benchmarking for key health outcomes, and unsurpassed general practice patient satisfaction.
Over the past five years, the GP/practice nurse/allied health practitioner team has progressed a collaborative general practice team that has taken this even further, with the absolute preservation of continuity of care. This is the model Australian consumers have overwhelmingly endorsed.
Unravel this, without clear benefit and evidence, at your peril.
This article is based on a speech Professor Jackson made at the RACGP GP09 conference earlier this month.

Professor Jackson is head of the discipline of general practice at the University of Queensland.


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