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"Thoughts on Health Care Delivery (1) The Potential of Primary Care"

The potential to reduce the burden of disease lies to some extent in the timely intervention in acute problems but also more in the prevention of disease in the first instance and in the prevention of complications in those with chronic medical problems like diabetes mellitus, hypertension and bronchial asthma. These are important tasks in primary care which, in Singapore, is provided by family doctors and doctors in the Government Polyclinics. Some primary care is also provided by specialists.

Prof Nigel Stott and Harvard Davies developed in the 1970s, an aide memoire on the potential of the consultation in general practice. They said that the doctor needs to consider in any consultation, four areas A, B, C and D. These stand respectively for acute conditions, behavioural modification of the patient, chronic conditions and disease prevention through opportunistic health promotion.

Quite obviously timely intervention in acute problems is important. A stitch in time saves nine. There is also the need for doctors to suggest modification of help-seeking behaviour which is inappropriate. Some examples come to mind. The desire for instant cure may be an illusive one as diseases have their time course. In trying to please patients, some doctors have resorted to the use of steroids and antibiotics where these are not indicated. Perhaps, we should be more assertive and take the initiative to explain to the patient and try to make him or her understand.

It is perhaps in chronic medical conditions that the potential for reducing disease burdens is relatively untapped. Presently across the world, the care of chronic medical conditions is inadequate and fragmented. More time is needed to go through the tasks of the consultation including enabling the patient with skills for self-care. The patient also needs all the motivation and encouragement that the doctor can give him or her.

Then, there is opportunistic health promotion in the consultation. The teachable moments to help the patient stop smoking, reduce weight and have regular exercise are many. Time spent on such activities over time may get the most resistant patient to change his lifestyle. This is not easy but it is worth trying.

To maximise the potential of the consultation in general practice requires a new understanding and the adoption of the concept of what has been coined by champions of primary care as a "mutual investment company". This company consists of the patient, his employer who pays his bills and the doctor. As a medical profession, we need to take the initiative.

To be able to maximise the potential of the consultation in general practice, there is a need to spend enough time with the patient. It has been found that six to ten minutes are needed for an average consultation. This may not be compatible with the average GP having to see as many patients in one hour as possible, merely to be confident of covering his operating costs. Food for thought.