Study shows GP care is key medicine for healthcare systems

For all our rapid advances in technology, sometimes the old ideas are best. Two strong arguments in favour of traditional modes of medical practice have emerged in the last couple of weeks: one in the form of a British Medical Journal (BMJ) study and the other from the respected surgeon/writer Atul Gawande in the New Yorker.

In his piece, headlined “The heroism of incremental care”, Gawande argues that the US medical system rewards heroic intervention and undervalues incremental care. He juxtaposes the firefighting, saviour role of doctors applying life-saving interventions with the challenge of looking after people with long-term, chronic illness.

Part of his personal journey is the realisation that primary care does a lot of good for people –“Maybe even more good, in the long run, than I will as a surgeon.”

Gawande wants us to recognise and embrace what he calls “incrementalism”. In other words to use our capacity to monitor the body and brain for signs of future breakdown and to intervene at stages along the way by practising “precision medicine”.

Allocation of rewards

There is, however, a major stumbling block: “The potential for incremental medicine to improve and save lives is dramatically at odds with our system’s allocation of rewards.” Put bluntly, all western health systems put the vast majority of their funding into acute, dramatic interventional medicine and a paltry amount into step- wise incremental care.

Perhaps the piece’s starkest statistic is Gawande’s assertion that more than a quarter of Americans and Europeans who die before the age of 75 would have lived longer had they received appropriate medical care for their mainly chronic health conditions.

The BMJ study, original research that cleverly mines existing health data in England, is the first to show that patients who received more of their medical care from the same GP were less likely to be admitted to hospital for a range of common conditions.

Using linked hospital and primary-care records from 200 general practices, Dr Isaac Barker and his colleagues from the Health Foundation in London identified some 230,742 patients aged 62-82 who had at least two contacts with a GP between 2011 and 2013. They then calculated the number of hospital admissions these patients had for what they defined as ambulatory care-sensitive conditions (ACSCs) – essentially diseases considered manageable in primary care.

ACSCs include long-term conditions such as asthma and diabetes, where good-quality care should prevent flare-ups; acute conditions such as gangrene, where timely and effective care prevents the condition developing; and conditions preventable by vaccination, such as influenza and pneumonia.

Continuity of care

Researchers found continuity of care tended to be lower in larger practices. But patients who saw the same general practitioner a greater proportion of the time experienced fewer admissions to hospital for ACSCs than other patients.

Indeed, compared with patients with low continuity of care, patients with medium continuity of care experienced almost 9 per cent fewer admissions, and those with high continuity of care experienced just over 12 per cent fewer. Of note is that this association was especially true among patients who were heavy users of primary care (more than 18 visits over a two-year period).

The BMJ paper really puts it up to politicians and the Health Service Executive to move beyond their hackneyed lip service of expanding and resourcing general practice. It's an economic "no-brainer": emergency admissions for ACSCs accounted for £1.42 billion sterling of health spending in England for 2009-2010. Aim for a 10 per cent cut in emergency admissions as suggested in the study and you are saving serious money.

It is also chimes with Gawande’s arguments. And while we will draw the line at a return to avuncular, pipe-smoking, tweed-wearing GPs, it seems that old style of continuing care has a lot to recommend it.