Should GPs oversee public health?

The Marmot review has called for GPs to play a greater role in improving public health. Stephen Robinson reports.

Under new proposals GPs will be expected to be more involved in tackling public health problems like obesity (Photograph: SPL)
Under new proposals GPs will be expected to be more involved in tackling public health problems like obesity (Photograph: SPL)

GPs' contracts should prioritise tackling health inequalities, according to the government review published this month by Sir Michael Marmot.

The review, Fair Society, Healthy Lives, says primary care should act as a 'focus hub' within local communities.

Practices could be bastions of preventive healthcare services and GPs incentivised through more public health- orientated indicators in the QOF, Sir Michael says.

The Conservative Party has similar ideas. It would realign GPs' income to incentivise preventive care if elected this year, according to its Green Paper, A Healthier Nation.

But should it be general practice's role to tackle public health as well?

Time for change?
'Yes, definitely,' says Professor Alan Maryon-Davis, president of the Faculty of Public Health. He believes the involvement of general practice is 'crucially important' in addressing local public health.

'GPs understand people in the context of their local environment,' he says. 'People are motivated to see their GP; they are more receptive to advice and more likely to follow it.'

Prioritising public health is a key Conservative pledge - the party plans to rebrand the DoH as the 'Department of Public Health'.

The department would 'shift its focus firmly to the prevention of illness rather than just its cure', the Conservatives say.

Within this, it sees a 'new role' for GPs in the community. The party wants to rework practice incentives to meet public health targets, beyond the disease registers in existing guidance.

New population health incentives, piloted as QOF indicators, would be the first step towards a rewritten contract that would require GPs to play a full role in public health initiatives.

Preventive care is at the centre of Labour's plans as well. Its healthy lifestyle campaign 'Change4Life' was re-launched last week for middle-aged people. The £2.7 million project, which encourages exercise and smaller meal portions, was launched the same day as figures suggested three quarters of the adult population will be overweight or obese by 2020.

The National Association of Primary Care (NAPC) says it supports greater collaboration between health and social care to meet these goals.

'Population health will become of increasing interest to GPs,' says Dr Johnny Marshall, NAPC chairman. 'In partnership, (patient) and public health could be more effective.'

And while Sir Michael and colleagues accept that GPs do not see tackling the social determinants of health inequalities as core business, they maintain that practices should still be at the heart of public health, with a greater focus on prevention.

Warnings
However, the GPC warns against engaging GPs in more public health work. 'The biggest changes that can be made to address health inequalities are outside the control of the NHS - let alone general practice,' says GPC deputy chairman Dr Richard Vautrey.

'GPs' main focus is on their individual patients. (They) are not public health specialists.'

He points out that GPs already work with public health teams in primary care organisations through general health assessments and commissioning services, like sexual health and cardiovascular disease screening.

However, he adds that, in many areas, 'GPs have not been sufficiently supported to get involved'.

The NAPC says the DoH and the NHS both clearly understand that the UK needs more preventive services, and believes increased practice involvement could be one solution.

But the NAPC thinks nurses should lead practice participation in public health services, because this offers better value for money.

'There is the right skill mix in practices, which can work well with social care in the community,' says Dr Marshall. 'I do not think this is necessarily a GP role.'

Above all, the government needs to ensure any increase in workload for practices is met with resources, so that initiatives do not detract from primary care services, says Dr Marshall.

The NAPC believes general practice is prepared to work 'hard and smarter' if resources and backing are provided.

PUBLIC HEALTH ROLE FOR GPs

How the review by Sir Michael Marmot proposes an expansion of GPs' role in public health work

  • General practice to take population perspective and tackle health inequalities.
  • Shift spending from acute to preventive care.
  • Scrap QOF upper limits to allow 100 per cent care coverage.
  • Indicators changed to promote preventive care services.
  • Practices to be 'revitalised' to offer targeted screening among disadvantaged groups.
  • Primary care to act as 'focus hub' for local communities.

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