Primary care and distributive justice
There is a famous WHO Alma-Ata statement which declares that primary care should be made universally accessible to individuals and families in the community, by means acceptable to them, through their full participation, and at the cost that the community and country can afford to maintain in the spirit of self-reliance[and] addresses the main health problems in the community, providing promotive, preventative, curative and rehabilitative services accordingly.
Factors affecting access to health include finance, ideology, and education.
Factors affecting access to health include finance, ideology, and education.
Six GP job descriptions
(Compare triage clinics with normal surgery.)
- To clear the waiting room efficiently (kindly if possible) only spending yourselfet al to gain specified worthwhile health gains. (No time wasters, please!)
- Get me better, so that I can go on doing the things that made me ill
- To do whatever the patient wants, within the law, usually. (I'm a nice guy.)
- To deal with local realities (loneliness, addiction, poverty, and mental illness) rather than hoping for diagnostic wonders to test your brilliance.
- To be skilled in: prioritization; delegation; health-need measurement; rationing; purchasing/delivery of healthcare; time- and staff-management.
- To care for people irrespective of age, sex, sexual orientation, race, illness, or social status. To make early diagnoses, framed in physical, psychological, and social terms. To make initial decisions about all problems presented or unearthed. To arrange continuing care of chronic, recurrent, or terminal illness. To practise in co-operation with colleagues, medical and nonmedical. To treat, prevent, and educate to promote health of patients and families, while reconciling professional responsibility to the community.
Health
Five definitions to compare:
- Health is the absence of disease or:
- A state of complete physical, mental, and social wellbeing. WHO definition1
- A process of adaptation, to changing environments, to growing up and ageing, to healing when damaged, to suffering, and death. Health embraces the future so includes anguish and the inner resources to live with it.I Illisch, 1976
- Any process enabling the giving or promoting of life.
- Health is whatever works, and for as long.J Stone, 1980, In All This Rain2
All the above have limitations, but 1 and 4 seem least counter-intuitive. Consider the following:
- Was Charles I healthy as he laid his head on the executioner's block?
- What about a priest in the act of losing his celibacy?
- Can a heart with a prosthetic valve which is gradually wearing out be healthy?
- Was Gandhi healthy at the end of a hunger strike?
- Can animals or babies be healthy?
- What about death in childbirth?
Answers below:
| Healthy according to definition:[bomb] | |||||
| 1 | 2 | 3 | 4 | 5 | |
|---|---|---|---|---|---|
| King Charles on the scaffold | yes | no | yes | yes | no |
| Fasting Ghandi | yes | no | yes | yes | yes |
| Babies and animals | yes | yes | no | yes | yes |
| Heart with failing valve | no | no | no | yes | yes |
| Priest losing his celibacy | yes | no | yes | yes | yes |
| Death in childbirth | no | no | yes | yes | yes |
Measuring health
Scores on the health survey Short Form 36 (SF36) are reproducible and quantifiable, related to patients clinical state, the GP's decision to refer, and GP's views on severity. It is valid when combined with a patient-generated index of quality of life (name the 5 chief activities/areas affected by your conditionand rank importance of improvements to them) and a daily time trade-off calculation (how much time would you give up to be in perfect health?). By combining instruments, defects in one can be mitigated (eg the SF36 asks if health limits your ability to walk a mile irrelevant if you do not need or want to walk much). Health need is the difference between the state now and a goal. Needs may be ranked by the distances between states and goals.
Advertisements
