Medical care begins at home

The government has committed itself to a major reform of primary health care. This will presumably involve improving available community-based medical services, providing new community services and facilitating private primary medical care with improved access to new and existing services and therapies. The drive for such a reform is the increasing expense of secondary medical care provided in hospitals, which is not necessarily superior to more accessible and less expensive care provided closer to home.

Recently a number of organisations, each representing a particular segment of family doctors working in Malta, have promoted the cause of supporting primary health care. The most development is the setting up a multi-disciplinary and international organisation with broad local and international support to promote research and training in the primary healthcare sector.

The Mediterranean Institute of Primary Care (MIPC) was inaugurated in Malta on May 23 as a non-governmental organisation supporting academic development of primary health care through research and training programmes. The institute is led by an international advisory committee with members from Malta, Italy, Turkey, and Greece including eminent international researchers in the field of primary care. It is chaired by Dr Inge Okkes, formerly of the University of Amsterdam. The authors of this article are the executive directors for training and research respectively.

The institute's inauguration was followed by the first MIPC conference on May 24, organised in collaboration with the Medical Association of Malta (MAM). The event was well attended by local family doctors as well as by high-level government officials including Parliamentary Secretary for Health Joseph Cassar. MIPC and MAM plan to continue to collaborate closely in the promotion of primary care.

The MIPC currently has around 50 members, including academics from Malta and the Mediterranean region involved in research in primary care, who have a background of family medicine, community gynaecology, nursing, pharmacy, physiotherapy, psychology and others.

The institute's objectives are ambitious and include supporting, commissioning, co-ordinating and conducting research aimed at improving health care delivery and patient outcomes; offering a central administrative office and trained study co-ordinators to support clinician participation in clinical research; generating research to support the practice of evidence-based medicine; providing opportunities for junior physicians to develop research skills in study design and analytic methods; and providing multidisciplinary training to conduct independent research relevant to primary care.

The MIPC is planning a number of training courses over the next 12 months including evidence-based medicine, research methods and basic surgical skills courses amongst others. The institute is currently involved in a two-year Seventh Framework programme-funded research project on assessing over-the-counter prescribing in primary care, co-ordinated by its Greek international advisory committee member, Prof. Christos Lionis. It plans to support many such research projects in future.

There is ample evidence that primary care is more effective in preventing illness and death when compared to health care systems that feature strong secondary care structures. The reasons for this are many, and include the fact that appropriate referrals to secondary care by a primary care doctor familiar with the patient, reduce unnecessary investigations and procedures which may harm patients. Contemporary medical care brings dangers as well as benefits, and primary care doctors are trained to ensure that only those patients who are likely to benefit from specialist care are exposed to it.

Money invested in primary care, whether government-funded through practitioner salaries, or through insurance-based or co-payment systems, pays dividends in the form of the most cost-effective type of health care.

Primary care is the key to cost-effective health care systems and better health outcomes. The work of Barbara Starfield and her team at Johns Hopkins University in Baltimore has shown that the stronger a country's primary health care system, the better the health outcomes and the more cost-effective the system as a whole.

Typically, within the period of a year, between 75 and 85 per cent of people in a general population require only primary-care services. Of the remaining population, 10 to 12 per cent requires referral to secondary care for short-term consultation, and between five to 10 per cent need to be referred to a tertiary care specialist for unusual problems.

This so-called 'gate-keeping' role of family doctors is at the core of primary care services in countries such as the UK, Ireland, and The Netherlands. The first-contact feature of primary care implies that patients do not visit specialists without a recommendation from their primary-care practitioner.

Most episodes of care start and end in the family doctor's office. It is frustrating that many of the conditions resulting in preventable hospital admissions are ones which can easily be managed in the community setting. For example, diabetes and cardiovascular disease, which account for a significant proportion of preventable hospital admissions, can be successfully treated by GPs and a primary care team in the community.

However, in Malta more than two-thirds of the 111,688 people attending the Mater Dei emergency department in 2007 went there without first consulting their family doctor. Placing the family doctor between the patient and the hospital protects patients by reducing both unnecessary procedures and possible complications.

Expanding primary health care services may not always reduce costs because good family doctors may identify previously unmet needs, thus expanding service utilisation.

However, health care systems with strong primary care elements are associated with a more equitable distribution of health in populations, achieved by removing barriers to health care access for socially deprived people.

The role of primary care should not be defined in isolation but in relation to the constituents of the health care system. Primary and secondary care, generalist and specialist, all have important roles in the health system.

They are not mutually exclusive, but rather necessary ingredients for the system to work effectively and efficiently.

However, technological advances, improved education and training, broadening of the roles of the primary care team, different demand patterns due to health transition, and changing social attitudes mean that primary care has a greater role to play than ever before, and resource allocation needs to flow in its favour.

The MIPC welcomes members from all Mediterranean countries and from all the disciplines involved in primary care. Enquires about membership should be directed to mipc@yesitmatters.com.

Dr Stabile is a senior lecturer in the University of Malta's Faculty of Medicine and Surgery, and a visiting professor at Florida State University College of Medicine, US.

Prof. Soler is a family doctor and a visiting professor from the University of Ulster, N. Ireland.