One answer is wealth. With wealth comes more stable political systems, and these are what are necessary for literacy and education to flourish, which in turn leads to easy access to clean water (the key issue, as more than 1 billion people have no such access), and the possibility of developing equitable health delivery systems. After clean water, the next steps focus on better nutrition, smaller families, more self-help, and anti-HIV strategies.
How do you move a Western post-industrial population from a low level of health to a higher level of health?It's no good relying on the altruism of doctors to introduce public health measures into every consultation. A more systematic method is needed. Since 2004, UK NHS primary care has been a vast multi-million pound test-bed of a payment-by-results system. Over 25% doctors' income can now depend on meeting very specific targets, eg: 70% of hypertensives to have BP 150/90; 60% of those with ischaemic heart disease to have cholesterol 5mmol/L. For diabetics: 50% to have an HbA1c 7.4% and 55% to have BP 145/85-etc. How successful are these targets? It is too early to quantify this, but most practices worked very hard and met most targets (far more than were expected). So the conclusion is that you need money and altruism to improve population heath. For the down-side of payment-by-results, see p 490.
Future determinants of health are thought to rest on:
- Reducing inequalities in access to health care, and in its content.
- Decline in tobacco consumption in all age groups.
- Better health services with more effective, more acceptable treatments.
- Fewer underdoctored areas (currently defined as populations where there are fewer than 52.695 GPs per 100,000-ie a list size of >1898 per whole-time GP)-and more GPs in deprived areas. Funding more GPs has been calculated as one of the most efficient ways of reducing mortality.
- Education capable of influencing behaviour to â†"exposure to risk factors.
- Better protection of the environment and better housing.
- More patient-centred health care, so that patients are not passive recipients of care, but well-educated partners in the struggle against disease.
Core competencies European academy of teachers in general practiceEUARACT
Turning Cliches into Health: is it possible?
- Dealing with unselected problems covering all health issues, co-ordinating care with other professionals in primary care and with other specialists.
- Adopting a person-centred approach-seeing patients in the context of social realities; using the consultation to bring about an effective doctor-patient relationship, with respect for the patient's autonomy; to communicate, set priorities, and act in partnership; to provide longitudinal continuity of care as determined by the needs of the patient.3
- To adopt appropriate working principles, such as incremental investigation, using time as a tool, and to tolerate uncertainty.
- Being able to manage many simultaneous complaints and pathologies- acute and chronic-at the same time as promoting health and well being-by applying health promotion and disease prevention strategies.
- Community orientation includes the ability to reconcile health needs of individual patients and those of the community in which they live.
- Holistic modelling1:the ability to use a bio-psycho-social model taking into account cultural and existential2 dimensions in non-reductionist thinking.
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