DR JULIAN TUDOR HART, HONORARY DOCTOR OF SCIENCE UNIVERSITY OF GLASGOW, 16 TH JUNE 1999

BIG IDEA APPLYING EPIDEMIOLOGY TO CLINICAL CARE

Once upon a time, you could measure the blood pressure of all your patients, and publish the results in the Lancet Lancet 1 st August 1970

TWENTY FIVE YEARS OF CASE FINDING AND AUDIT IN A SOCIALLY DEPRIVED COMMUNITY Julian Tudor Hart British Medical Journal % reduction in premature mortality over 25 years, compared with conventional care in a neighbouring village

NOT ONLY Evidence-based medicine (QOF, SIGN) BUT ALSO Unconditional, personalised, continuity of care, provided for all patients, whatever problems they present.

HK, aged 42 Persistent disability from major compound fracture Very high blood pressure, 200/120 mm Hg Very high cholesterol, 9.5 mmol/l High blood uric acid High alcohol intake Obesity

Overall the story is a success … For the staff at our health centre it was a steady unglamorous slog through a total of 310 consultations. For me it was about 41 hours of work with the patient, initially face to face, gradually shifting to side by side. professionally, the most satisfying and exciting things have been the events that have not happened : no strokes, no coronary heart attacks, no complications of diabetes, no kidney failure with dialysis or transplant. This is the real stuff of primary medical care. A New Kind of Doctor

PRIMARY CARE TRAJECTORIES 1.From pastoral care to interventional care which alters the natural history of conditions 2.From reactive care, focusing on the presenting complaint, to anticipatory care, attempting to delay or prevent future problems. 3.From passive patients to active patients, with increased agency and responsibility for their own care. 4.From single episodes to sequences of care, requiring continuity, relationships and trust 5.From care of the individual to care of the population, including the idea of equity based on need 6.From pragmatism and good conscience to systematic efforts to improve the quality of care, based on evidence and audit 7.From individual professional activities to team work 8.From the local team to the wider team, involving colleagues from other agencies 9.From isolated local units of care to consideration of primary care as a whole system 10.From the medical model to a social model of health and health care within communities 11.From professionalism to participative democracy 12.Leading all or some of the above

IDEAS THE MEDICAL MODEL diagnosis, treatment, prevention PATIENT-CENTRED MEDICINE Ideas, concerns, expectations, empowerment CONTINUITY AND INTEGRATION Communication, teamwork POPULATION Quality, organisation, equity SCIENCE Measured doubt, limitless faith COMMUNITY Building local health systems around practice hubs

4 KEY ELEMENTS OF PRIMARY CARE First contact Continuity Comprehensiveness Co-ordination STARFIELD

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NEW FEATURES OF PRIMARY CARE COVERAGE (90% is standard) QUALITY (audit and evidence) PRIMARY CARE MAKES A DIFFERENCE

IN PLACE OF FEAR ANEURIN BEVAN

The challenge of universal coverage

WRITING A REPORT ON HEALTH INEQUALITIES AND GENERAL PRACTICE 1.Not another report that sits on the shelf, and makes no difference 2.No tool kit, telling GPs what to do 3.Start by listening to GPs in the front line TIME TO CARE Health Inequalities, Deprivation and General Practice in Scotland RCGP Scotland Health Inequalities Short Life Working Group Report December 2010 “Practitioners lack time in consultations to address the multiple, morbidity, social complexity and reduced expectations that are typical of patients living in severe socio-economic deprivation.”

DIFFERENCES IN LIFE EXPECTANCY BETWEEN MOST AND LEAST DEPRIVED DECILES SCOTLAND 2007/08 MEN MostLeastDifferencedeprived Life expectancy Healthy life expectancy Years spent in poor health WOMEN MostLeastDifferencedeprived Life expectancy Healthy life expectancy Years spent in poor health Long-term monitoring of health inequalities. The Scottish Government 2010

GENERAL PRACTITIONERS AT THE DEEP END

INVERSE CARE LAW “The availability of good medical care tends to vary inversely with the need for it in the population served”. The inverse care law is a policy of NHS Scotland which restricts care in relation to need. Not the difference between good and bad care, but between what general practices can do and could do with resources based on need.