A stitch (of primary care) in time

Astika Kappagoda
Med J Aust 2014; 201 (7): 367. || doi: 10.5694/mja14.c1006
Published online: 6 October 2014

Management of a patient's immediate problem has never been the only goal of a general practice consultation. It is good that each episode of primary care is increasingly recognised for its role in a patient's health trajectory and in wider community-level health. Primary and community care are powerful means for preventing illness or complications and protecting those at risk.

Primary care is the main vehicle for the Healthy Kids Check (HKC), which may be having a positive impact on managing child health. Thomas and colleagues, in their audit of the medical records of two Queensland practices (doi: 10.5694/mja14.00637), show that the HKC assisted in identifying problems in 116 out of 557 children, 3%–11% of whom required a change in clinical management. The HKC also spurred general practitioners on to consider aspects of a child's health that it did not cover. Oberklaid (doi: 10.5694/mja14.01200) says that although the concept of a general health screen is intuitively appealing, implementation is challenging in terms of population coverage, interpreting results against normal developmental variability, and getting timely intervention for detected problems. Responding to parents' concerns is the cornerstone for early detection and prevention, and primary care plays an important role in increasing the emphasis in health care on prevention.

At the other end of the lifespan, GP consultations present the opportunity to reconsider older patients' regular medicines. Reeve and colleagues (doi: 10.5694/mja13.00200) highlight the importance of deprescribing in resolving unwanted drug effects and increasing adherence to needed medicines. But they also emphasise caution so as to reduce adverse drug withdrawal reactions and disease re-emergence, and they point out the lack of evidence to construct optimal methods to deprescribe. Likewise, Scott et al (doi: 10.5694/mja14.00146) highlight the barriers to deprescribing and emphasise the need to have holistic discussions with patients of its risks and benefits so that deliberate and considered plans for withdrawing medications are formulated.

Reconsidering a patient's medication burden naturally leads to a rethink of how underlying chronic conditions should be managed. This is particularly pertinent with regard to chronic pain. Although early intervention and referral to specialist services are common for other chronic conditions, Cousins and Brydon (doi: 10.5694/mja14.00572) emphasise that this is lacking for the one in five Australians in chronic pain. Given the current overreliance on opioids and the long waiting times to attend pain clinics, they welcome National Pain Strategy recommendations to provide resources and training for GPs, establish multidisciplinary regional pain centres and set levels of care based on case complexity.

Early prevention and detection through primary care should also apply to mental health in people of all ages, as Reavley and Jorm argue (doi: 10.5694/mja13.00198). They welcome increases in mental health resourcing and service availability over the past two decades, and the reduction of some measures of mental illness. Yet population health-oriented strategies for early detection and support for people, starting early and continuing throughout the lifespan, are more likely to produce substantial improvement for less cost.

The health of vulnerable populations also falls within the purview of community care, and practitioners may feel hindered in their efforts to help. Corbett and colleagues (doi: 10.5694/mja14.00279) found responses by general and community paediatricians to a questionnaire assessing knowledge and attitudes to asylum seeker children revealed that most are strongly supportive of the Australian Medical Association's position on children in immigration detention and strongly opposed to offshore detention. But notable gaps exist in knowledge of Medicare eligibility rules, hospital fee-waiver programs and screening tests conducted for visa applications. The paediatricians are well motivated to help these vulnerable children but would be aided by better knowledge of the administrative mechanics.

GPs and others working in community health care should be confident that their clinical practice for individual patients has positive lasting effects on their and their communities' health. Patient-centred primary care that acts in a timely way and directs further care appropriately will continue to be effective in these respects.

  • Astika Kappagoda

  • Medical Journal of Australia, Sydney, NSW.



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