Summary

The primary-care-led National Health Service in the United Kingdom (UK) includes the key features of general practice - continuous, comprehensive personal care delivered over an extended period. General practitioners orchestrate the activities of the many individuals and agencies involved in the care of patients with chronic disease, and contribute to a more cost effective health care system. Teaching and research in general practice also need to be established to maintain knowledge and standards of practice. The development of strong primary health care with well trained general practitioners linking the achievement of clinical standards to remuneration, provision of a wider range of services for patients through strong team work, and the provision of good accessible services will help to minimise the problem of health inequality as the hospital services move towards a market system in mainland China. This review of UK primary health care and the academic development of general practice may act as useful reference for the development of community based health services in mainland China.

摘要

由基層醫療服務帶頭的英國國家衛生服務體系包括了基層醫療的重要特徵，在較長時間內提供連續性、綜合性、個體化的服務，全科醫生協調許多個人和機構共同參與慢性病患者的保健和治療，使得衛生服務系統更具成本效益。同時也需要開展全科醫學的教學與研究工作，以保持學科的知識體系和水準。發展強有力的基層醫療服務，配以訓練有素的全科醫生，並將臨床水平與薪酬相聯繫，透過有力的團隊合作為病人提供更廣泛可及的優質服務，有助減少中國大陸醫院服務轉向市場體系帶來的健康不公平問題。對英國基層醫療服務和全科醫學學術發展的回顧，可以做為中國大陸社區衛生服務的良好借鑒。

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Introduction

The United Kingdom (UK) has a long-established and effective system of primary care provision, based on general practitioners working in multi-disciplinary teams and acting as gatekeepers to secondary care. Many aspects of this system may be of interest to countries developing their own primary care service. In this paper we look critically at the way in which the primary care system works in the UK and at its possible relevance to mainland China's developing health care system.

Background

In 1948 the UK Government established the National Health Service (NHS), a comprehensive system of health and social care which would be made available to citizens without charge at the point of need, and would be funded out of general taxation. The creation of the NHS is recognised as being a remarkable leap of imagination and of political vision, all the more so because it was conceived and born during a period of conflict and austerity. Some of the key features of the NHS are summarised in Table 1.

Table 1: Main features of The UK National Health Services

Free at the point of need: a federal responsibility Registration of the entire population with GPs (capitation payments cf fee for service) General practitioners' 24 hour responsibility for providing care Sharp division between primary (general practice) and secondary (hospital) care: referral system, waiting lists Teaching and research located initially entirely in hospitals: reflected in contracts Modest proportion of GDP spent on the health service

The implications for the provision of primary care services, through the general practitioner (GP) system, were nothing short of revolutionary. Although the concept of registration of each citizen with a single GP was rooted in the National Insurance Act of 1911, and the principle of referral from GPs to specialists had even earlier origins, whole-population registration, with payment to GPs based on capitation, rather than on an item-of-service system, represented a major change. This was accompanied by legal responsibility for GPs to ensure that their patients had access to care (either directly or by delegation) 24 hours a day.

The structure of the NHS sharpened the division between primary care (general practice) and secondary and tertiary care (hospital medicine). Patients were able to see a specialist in a hospital clinic only if they had been referred by letter from their GP. Teaching and research in the health service were located, at least initially, entirely in hospitals, and this was reflected in the contractual arrangements for hospital doctors and general practitioners. Because it was necessary for the Government to pay high-earning specialists substantial sums to persuade them to give up their private practice and take up salaried posts in the NHS, the remuneration, and with it the status, differential between hospital medicine and general practice was confirmed.

For many years the NHS operated effectively. The service was greatly appreciated, indeed loved, by the general population, people working in the NHS were accorded a remarkable degree of respect and appreciation, and morale was generally high - people were proud to work in the health service because of its altruistic guiding principles. At the same time it became clear to health economists that the UK's health service was being provided relatively cheaply - the proportion of gross domestic product (GDP) spent on the NHS in the UK was substantially less than that in many European countries and, as health care costs began to rise towards the end of the 20^th century, very much less than the expenditure on health care in the USA and elsewhere.

Figure 1: Health care expenditure of different Nations
(we need a more up to date version of this)

1998 Total Healthcare Spending % GDP by Nation
Grandfather Healthcare Report
http://home.att.net/-mwhodges/healthcare.htm

General practice and primary care

The last 50 years have witnessed a remarkable transformation of general practice in the UK, to the extent that in the late 1990s and the early 21^st century the UK,s Department of Health has regarded primary care as being at the core of the health system, reflected in phrases such as 'a primary care-led NHS', and a strong policy focus on community-based services in the most recent document 'Our Health, Our Care, Our Say,.¹

Registration

The key building blocks of a strong primary care sector, based on GPs and their teams, are summarised in Table 2. First the registration system, accompanied by a capitation-based system of payment, has been very important in providing a foundation for the delivery of both individual and population-based health care. This system of payment, based on the number of patients for which a GP has clinical responsibility, rather than remunerating the GP on the basis of items of service provided, is at the heart of a cost-effective service. GPs are encouraged to be parsimonious, and to use resources wisely and sparingly, rather than seeing each patient as an opportunity to make a referral, undertake a procedure or arrange an investigation to increase income. Linked to this, the registration system provides a population denominator, so that it is possible to measure accurately activities such as childhood immunisation, cervical cytology uptake rates and screening for cardiovascular risk factors. Clinical audit and research are greatly facilitated by the availability of an accurate denominator, within which the demographic features of the practice population are included, and beyond which there is an opportunity for outreach and pro-active care, so that GPs can contact their patients directly to remind them about the need for preventive care or changes to treatment.

Table 2: Key features of general practice

Registration and capitation systems Continuity, comprehensiveness and co-ordination Group practice with multidisciplinary teams Information systems Training for the speciality of general practice Teaching and research in general practice

Continuity, comprehensiveness and co-ordination

Closely linked to the personal registration system have been certain elements of general practice in the UK, which have come to be regarded as core features of general practice around the world. These include continuous, comprehensive personal care delivered over an extended period, accompanied by a co-ordinating role, in which the GP orchestrates the activities of the many individuals and agencies involved in the care of patients with chronic disease, including hospitals, social, community nursing and mental health services. Barbara Starfield's extensive international analyses of primary care services strongly support the view that a primary care service embodying these qualities is likely to lie at the heart of a cost-effective and clinically-effective primary care service.²

Groups and teams

Solo general practice is now rare in the UK, although single-handed practice was common 30-40 years ago. GPs have been encouraged to work together in group practices, many with the characteristics of small businesses, in order to share responsibilities and to provide a greater range of services and better accessibility and quality of care for their patients. The incentives to do this have included the provision of financial allowances to encourage the development of suitable premises and additional payments for doctors working in a group practice.

The trend towards group practices has been accompanied by the development of the primary health care team (PHCT).³ This is founded on the concept that effective primary health care cannot be provided by an individual clinician, and that patients will receive a better quality of care if other clinical and non-medical disciplines are involved. The modern group practice in the UK will include doctors, practice nurses, nurse practitioners (nurses with an extended diagnostic and therapeutic role), health visitors, district nurses, counsellors, psychotherapists, drug, alcohol and mental health workers and many others, in addition to a full complement of administrative, reception and information communications technology staff.

Information technology

Computerisation has been a further important factor in supporting high-quality primary care in the UK, and despite current problems in implementing a national patient records system, computerisation in general practice has been years ahead of parallel development in the hospital setting, so that virtually all practices in the UK now use computers for registration, recall and audit purposes, and a substantial number, approaching a majority, conduct routine consultations which are either paper-free or paper-light, with the paper records being referred to only occasionally.⁴

Training for general practice

A key factor in creating a strong primary care sector has been the requirements for postgraduate specialist training in general practice and for continuing medical education. The College of General Practitioners was founded in 1962 and received its Royal Charter 10 years later. Shortly afterwards a mandatory system of vocational training was introduced, so that all doctors wishing to enter general practice following full registration were required to undertake a three year period of training, two years being spent in hospitals and the third year in an apprenticeship role as a trainee (now registrar) in general practice under the tutelage of a qualified trainer. In addition GPs were required to undergo 1-2 weeks of accredited postgraduate training each year, with financial rewards for those who undertook this and penalties for those who did not; this has now been replaced by a system of annual appraisal and an imminent system of re-validation, likely to be based on a rigorous 5-yearly review of knowledge, skills and attitudes.⁵

Academic general practice

In parallel to the development of the Royal College of General Practitioners' training and postgraduate functions, the university departments of general practice have also blossomed. The first chair of general practice was established in Edinburgh in the mid 1960's, and now all 30 English universities have at least one professorial chair of general practice; the university departments make a significant contribution to curriculum planning and delivery, with over 15% of medical undergraduates' clinical contact taking place outside the hospital setting. The departments are also responsible for undertaking programmes of research in primary care; successful programmes are typically multi-disciplinary, highly collaborative, often with strong links with specialist and secondary care departments, and focus on areas of particular relevance to general practice but which are also likely to yield generalisable results and high impact publications. The academic departments of general practice are subject to research assessment in the same way as other university research departments.⁶

Financial problems

By the late 1980s it was becoming clear that a high-quality health service was unaffordable at the current levels of investment and taxation. In an attempt to introduce competition and encourage efficiency, the Thatcher government of the last decade of the 20^th century introduced the so-called internal market, in which general practices fulfilling certain criteria were given their own budgets and the ability to spend their healthcare resources in whichever hospital or other specialist setting they wished, in order to obtain the best deals for patients - shorter waiting times, more rapid access to surgical procedures etc. This artificial internal market probably did lead to some improvement in quality among fundholding practices, but undoubtedly also led to a two-tier system, with patients not registered with fundholders experiencing worse access to services; in addition fundholding was associated with high management costs and manipulation. Its long-term outcomes were unclear, but this experiment in part-privatising the health service was brought to an abrupt halt when it was abolished by the Blair government when it came into power in 1997.⁷

Despite an increased level of investment in the NHS, with the current proportion of GDP approaching that of most of the OECD countries, the NHS has once again begun to look unaffordable. Blair's Labour government introduced a range of reforms, including Hospital Trusts, later Foundation Trusts, Primary Care Trusts (charged with the responsibility of commissioning services for primary care from hospitals) and a range of other initiatives largely associated with widening access, improving patient choice and increasing 'throughput' in selected clinical activities, such as accident and emergency departments and surgical wards. This has been an era of NHS targets - the two-week cancer waiting rules to ensure that patients with suspected cancer were seen by a specialist within two weeks of seeing their GP, criteria for the number of hours that patients should wait in accident and emergency departments before being seen by a doctor, and the number of days patients should wait before they are able to see the GP of their choice, and so on.⁸

NHS Direct

In an attempt to increase self-efficacy, to encourage self-management and to reduce the burden on out-of-hours services, NHS Direct, a nurse-led triage service, initially delivered by telephone and later internet-based, was introduced.⁹ Patients were able to call NHS Direct at any time and would be interviewed by a nurse, working to carefully-constructed diagnostic and management algorithms, who would give advice on the most appropriate course of treatment - self-care, contact with a GP, urgent contact with the hospital etc. The service appears to be working well, although NHS Direct is relatively expensive and it is not clear whether it has resulted in reduced demand on accident and emergency departments and improved health outcomes.^{10, 11}

The Quality Outcomes Framework

The most recent contractual arrangements for GPs in the UK are now based partly on capitation payments, and partly on a range of quality indicators which have been introduced, as part of the Quality Outcomes Framework (QOF), to link GPs' remuneration to their achievement of carefully-specified healthcare targets.¹² About half of these relate to chronic disease management - asthma, cancer, coronary heart disease, chronic obstructive pulmonary disease, diabetes, epilepsy, hypertension, hypothyroidism, mental health and stroke - and the remainder to practice management indicators, including organisational aspects of practice management, the quality of the patient experience and the provision of additional services. Examples of practice management indicators include access to a GP within 24 hours, adequate practice opening hours (over 45 hours per week), annual medication reviews, the provision of smoking cessation advice, maintenance of practice equipment, the provision of practice information materials and an annual appraisal system for practice staff. Payments to practices depends on the achievement of QOF 'points', providing incentives to improve care across a range of clinical and administrative activities.

Our Health, Our Care, Our Say²

The most recent strategy document from the Department of Health further emphasises the important role that primary care and community-based management are planned to play in the future. General Practitioners with Special Interests, providing intermediate care, and general practitioner hospitals, situated in rural areas of the country, are seen as important components of this policy, which also includes providing additional resources to continue the shift of care from secondary to primary care and for the support of community-based services, particularly those focused on mental health and sexual health.

Achievements

The NHS has undoubtedly provided a model of care in which a strong general practice sector, with a benign gate-keeping role, has contributed significantly to cost-effectiveness. Continuity, personal care, co-ordination and comprehensiveness have been the key features of general practice in the UK, which has been immeasurably strengthened by the introduction of mandatory vocational training for all GPs. Team working and group practice have also contributed strongly to the provision of a wide range of services for patients, and the provision of good access of out-of-hours cover. Most recently the introduction of the QOF has linked the achievement of clinical standards to remuneration in an innovative and positive way. Teaching and research are now established functions of general practice, both in the National Health Service and in the universities and the involvement of GPs in education - over 50% of GPs are involved in undergraduate teaching or postgraduate training - adds significantly to job satisfaction and to the ability to maintain knowledge and standards of practice.

Problems

The main problem facing general practice has been under-funding. Most of the difficulties that have been experienced over the last decade have been related to this, and many of the so-called NHS reforms have been attempts to maintain services in the face of shrinking resources. Concerns about quality, dominant 20-30 years ago, have receded, and the QOF and introduction of an annual appraisal system for GPs provides some reassurance for the future. The likely introduction of re-validation, with a 5-yearly assessment, is not far away, which will add further to public and professional confidence in the competence of GPs.¹³

It might be argued that general practice has not been as effective as it should be in articulating its core values, and that the central importance of personal continuity, longitudinal care and comprehensiveness are lost on health planners, who often threaten to de-construct general practice in an attempt to re-distribute resources and see new hospitals as the most valuable indicator of investment in health care. As alternatives to general practice as the source of primary care are introduced these developments need to be watched carefully, particularly as new, non NHS players enter the primary care arena, providing services on a commercial basis. Commitment and morale in general practice are precious and fragile commodities, and need to be guarded carefully.

Should China adopt the NHS Model of General Practice to face the new health challenge?

China is one of the world's oldest civilizations and one of the world's largest countries, with a population in excess of 1.3 billion. China has achieved tremendous economic success, and its economic growth of around 9% per annum since the late 1970s has helped to lift several hundred million people out of absolute poverty. China faces major challenges related to its continued rapid growth, however, including growing income inequality, unsustainable resource exploitation, and issues related to growing regional and global economic integration with substantial proportion of population not accessible to basic health and educational services.

Paradigm shift in health care system in China

During the second half of last century, China has gone through two distinct phases of development. It evolved from an egalitarian society during the period 50s to 70s to a new era of economic liberalization from 80s onward.¹⁴ During the first phase, the health improvement of the population was based on major investments in public health through a centralized government agency modelled on the Soviet Union system emphasizing the control of infectious diseases through immunization and the control of disease vectors, and use of minimally trained personnel ('barefoot doctors) to provide basic health services.^14-17 Infant mortality fell from 200 to 34 per 1000 live births, and life expectancy increased from 35 to 68 years.¹⁷ By the beginning of the 1980s, China was undergoing the epidemiologic transition seen in Western countries with the emergence of chronic, non-communicable diseases (heart disease, cancer, and stroke) as the leading causes of illness and death.¹⁷ However the improvement of health stagnated during this period of rapid economic growth with health development lagging behind the economic development resulting in inequalities in health and access to health services.¹⁷

Since the early 1980s, China has changed the way in which health care is financed. The central government's investment in health care services has been reduced, so that between 1978 to 1999, its share of national health care spending fell from 32% to 15%.¹⁸ Much of the responsibility for funding health care services was transferred to provincial and local authorities who were required to provide them through local taxation.¹⁹ Revenues were planned to be generated by developing new drugs, new tests and new technology.¹⁹ With an emerging market-based health care system, the ability to pay become the main factor affecting access to health care. Whilst 49% of urban Chinese have health insurance, only 7% of people living in rural districts are insured,²⁰ and health care is mainly provided by 'barefoot' doctors without formal medical school training.²¹ Rural people tend to bypass local doctors to seek help from expensive urban hospitals. It is clearly important for the government to ensure an effective health care safety net in this situation.²¹

Strong needs for good primary health care

If China's hospital services are moving towards a market system similar to the USA, it becomes more and more important to develop an effective system of primary care funded by the government to act as gatekeeper to hospital services as more than 135 million Chinese are living in remote and resource-poor areas without access to adequate health services.²² There is strong evidence for the association between effective primary care and improved health indicators^21-24 and, furthermore, primary care addresses the most common medical problems seen in the community. It integrates care where there is more than one health problem, and deals with the context in which illness exists. It influences the response of people to their health problems and organizes and rationalizes the deployment of health care resources. Shi et al²⁵ have developed a set of nested models which examine the independent effects of primary care and income inequality on mortality, and the extent to which the addition of primary care to the statistical model attenuates the association between income inequality and mortality. Primary care is inversely associated with total mortality and income equality has a positive association. The inclusion of primary care reduces the magnitude of all socio-demographic regression coefficients. These findings are particularly important in rural China, where residents have lower incomes than those in urban areas.²²

Apart from availability of high quality primary health care, the services need to be widely accessible, particularly to disadvantaged groups and a universal approach might not fully address the question of inequity. In a recent report Lee and colleagues²⁶ have described how the "Effective Primary Health Care" working in synergy with 'Healthy Setting' approach would ensure that the ethos of the setting and all the activities within it are mutually supportive and improve health and well being of those who live, work or receive care there, with full integration of health promotion activities. This approach can help to bring disadvantaged groups into contact with primary health care service, and shift the focus from risk factors to organizational change, so that sustainability of the system can be ensured. There is an urgent need to evolve a model of community health services with strong focus on primary care with "Integrated approach to manage and prevent non-communicable diseases". A strong team of well trained high quality primary care physicians is needed to meet the needs of the community through curative, preventive and rehabilitative services.

Conclusion: Is UK's NHS Primary Care model relevant to Mainland China?

Decentralised and fragmented health care system is not well suited to a country with large population such as China to make a rapid response to health crisis.²⁷ Increased market force in health care would bring in modern facilities but it only brings benefits to those who would afford to pay. The percentage of total expenditure on health funded by government has dropped from 22% in 1991 to 14% in 2000, and the percentage funded by individual increased from 38% to 60% during the period.¹⁷ Public health measures on disease prevention and health promotion will be compromised and public health investment on health was the main driving force to improve the health of the Chinese population in last century. As hospitals develop increasingly expensive, high-technology services, a state-run primary health care system may help to balance the problem of health inequalities and inequity. The NHS model of primary health care, supported by a quality assurance framework with strong focus on preventive medicine, is likely to be useful in the development of primary health care system in China. Health insurance system is unlikely to bring comprehensive coverage for the entire Chinese population particularly those living in remote and rural areas.

When one examines closer to the supply of primary care physicians disaggregating into family physicians, general internists, and paediatricians, only the supply of family physicians showed a significant relationship to lower mortality.²⁸ Recent study by Lee et al found that the prevalence rates of good health and hygiene behaviours and scores in all three main domains of the Children Behaviour Checklist (anxious/depressed, somatic complaints and aggressive behaviours) were higher amongst those children with regular family doctors.²⁹ Physicians need to be well trained in primary care to provide good quality primary care services. A system of good-quality primary care services might be able to reduce some of the ultimate consequences of social inequalities at the population level by contributing to reduced levels of disease transmission, lowering aggregate levels of risk factors (such as hypertension, smoking, weight gain), improving wide screening and early diagnosis activities, and developing systems to coordinate care.^30-31 The NHS primary care model developing in parallel with training and academic development will be relevant to China to establish a community health service model with high quality primary health personnel to serve large proportion of population that might not be able to access and afford hospital services in urban areas.n

Key messages

1. The last 60 years have witnessed a remarkable transformation of general practice in the UK with primary care being at the core of the health system and a strong policy focus on community-based services.
2. The proportion of gross domestic product (GDP) spent on the NHS in the UK was substantially less than that in many European countries.
3. A key factor in creating a strong primary care sector has been the requirements for postgraduate specialist training in general practice and for continuing medical education.
4. General practice has not been as effective as the central importance of personal continuity, longitudinal care and comprehensiveness are lost on health planners, who often threaten to de-construct general practice in an attempt to re-distribute resources and see new hospitals as the most valuable indicator of investment in health care.
5. Decentralised and fragmented health care system is not well suited to a country with large population such as China to make a rapid response to health crisis.
6. As hospitals develop increasingly expensive, high-technology services, a state-run primary health care system may help to balance the problem of health inequalities and inequity.

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Reference