Comparisons of UK General Practice and US Family Practice

J Am Board Fam Pract: first published as 10.3122/jabfm.12.2.162 on 1 March 1999. Downloaded from FAMILY PRACTICE - WORLD PERSPECTIVE Comparisons of UK General Practice and US Family Practice Daniel K. Onion, MD, MPH, Robert M. Berrington, MBE, FRCGP Both the United Statesl -3 and the United King the substantial differences between the health care dom4,5 are in the midst of major restructurings of systems and family-general practice education in their health care systems to expand and create Britain and the United States. Educators in both more central roles for primary care. These new countries can learn much from each other about approaches create valuable financial efficiencies training methods for common generalist profes and improve quality of care.6-13 sional skills. At the same time, however, they still In the United States extensive definition and must tailor their educational systems to produce planning for these changes has been ongoing for graduates who have the skills to succeed in their more than 2 decades, especially by family practice own national systems. A glossary of terms that educators. To a lesser degree, such planning has have different meanings in the United States and occurred in pediatrics and internal medicine, spe the United Kingdom is displayed in Table 1. cialties that share primary care responsibilities with family medicine. Only recently, in the past 5 Commonalties years, as a result of the dramatic shift to managed The essence of primary care has the same compo care health insurance systems, have the prestige, nents in both countriesll: first-contact medical income, and job opportunities led to a reversal of care provided continuously by the same doctor to the decline in primary care training. The number individual patients; comprehensive, without body of graduating US medical students choosing train system or disease agent restriction; coordinated ing in primary care was estimated to be as high as with social, nursing, and other paramedical ser 27 percent in 1995 14- 16 and 37 percent in 1997.J7 vices as well as with specialized, secondary and In the United Kingdom the role of the general tertiary medical care; holistic, considering both http://www.jabfm.org/ practitioner has been defined and redefined dur scientific and psychosocial aspects of patients and ing the past 25 years. 18,19 Although the UK gov their health status. In both countries primary care ernment has emphasized the key role of the gen doctors are clinical generalists who apply the sci eral practitioner in the primary care-led National entific disease model to illness, when appropriate, Health Service (NHS), in 1995 only 26 percent of then deliver or advocate for the patient to obtain doctors finishing their required preregistration medical diagnostic and therapeutic care, and fi on 27 September 2021 by guest. Protected copyright. (internship) year planned to enter general prac nally interpret the whole process to the patient. tice, a rate that represented a 20 percent decline When the disease model is inappropriate, the doc within the past 10 years20,21 despite strenuous re tor guards the patient against ineffective specialist cruitment campaigns by general practice educa referral, testing, treatment, and medicalization of tors. Thus, primary care in both countries ap nonmedical symptoms.22 peared to be at roughly the same recruitment level This latter portion of the role is often described in 1995, but on the rise in the United States while as "gatekeeper," a description that can falsely imply on the decline in the United Kingdom. the primary care doctor's primary duty is to ration In this article we examine the similarities and a medical "commons" rather than to advocate for the individual patient.9,23,24 The tensions between guardian and gatekeeping roles have increased re Submitted, revised, 10 April 1998. From the Maine-Dartmouth Family Practice Program cently in both countries. Health care payers have (DKO), Augusta, Maine, and The Anglia Deanery (RMB), created financial incentives for primary care doc Cambridge, United Kingdom. Address correspondence to Daniel K. Onion, MD, MPH, Maine-Dartmouth Family tors to ration medical services by capitating not Practice Residency, 15 E Chestnut St, Augusta, ME 04330. only primary care but also secondary care services 162 ]ABFP March-Aprill999 Vol. 12 No.2 J Am Board Fam Pract: first published as 10.3122/jabfm.12.2.162 on 1 March 1999. Downloaded from Table 1. Glossary of Tenns With Different Meanings and medical service needs that are met through in the United States and the United Kingdom. separate and minimally congruent delivery sys tems. Having generalist, one-stop social service USTenn UKTenn systems integrated with primary care medical Continuing medical Continuing professional practices could decrease the frustration of deliver education development ing primary care, especially to poor and mentally Faculty physician Trainer ill patients.30,3! In both countries fragmented, Family practice General practice rapidly changing, categorically organized social Internist Physician service and mental health systems remote from Junior resident, intern CRl) Preregistration house officer Junior resident (R2) Senior house officer medical practices prevent maximal coordination Office Surgery of social and primary medical care services. Even Office visit Consultation so, British home health nursing services are more Partner Principal closely linked with general practices than in the Physician Doctor United States by virtue of shared and defined geo Preceptor Trainer graphic territories, regular meetings, and often Residency program Training scheme shared office space. In its most recent White Pa Residency director Course organizer per on the National Health Service,28 the UK Resident Trainee government requires general practitioners to lead Senior resident (R3) Registrar multiprofessional primary care groups to manage Specialist Consultant community-oriented primary care locally. These Visiting or home health District nurse (community nurse nursing sister) groups will include nurses, managers, social work (No similar tenn or Higher professional education ers, and public health physicians as well as local training) (additional training while in general practitioners. practice immediately or soon after residency training) In both countries women represent an increas ing percentage (nearly 50 percent) of medical stu dents, postgraduate trainees, and practitioners in all fields, especially primary care.20.32.33 As a result, through managed care contracts in the United educational and practice systems are searching for States and by fund holding2s-n and, more recently, ways to accommodate part-time training and 28 commissioning in the United Kingdom. This work both for women who have traditional family http://www.jabfm.org/ conflict between the needs of the individual patient responsibilities and men who wish to assume and distributive justice for the collective good is greater responsibilities for child care. In both now a major ethical dilemma in both countries. countries the social values and work expectations In both the United States and United King of more recent generations of doctors are chang dom, primary care doctors are recognized as hav ing considerably.34 They seek increased medical ing an important role in promoting healthy life career structure flexibility3s and are more reluc styles at individual patient encounters,29 Overkill is tant to commit to the traditional 60-hour or more on 27 September 2021 by guest. Protected copyright. possible, however, and many British general practi work weeks and substantial personal financial in tioners reasonably point out that when health pro vestment in long-term practice commitments. motion is required by payers at the potential ex Furthermore, because a crucial and most profes pense of other, more appropriate types of care, sionally gratifying element of primary care is con elements of blaming the victims of inadequate tinuity of patient care, finding ways to balance re public health protection can result. For example, in quests for increased personal time without Britain until 1996 physician payments were effec sacrificing the essence of the professional experi tively contingent upon documenting that smoking ence is difficult but necessary in both educational cessation be brought up at every encounter with a systems. smoking patient. This policy has now been re In professional self-regulation, the United versed to allow practices to determine individually Kingdom adopted a uniform summative assess their health education strategies. ment method of certifying graduates of general UK primary care doctors and US primary care practice training programs in 1996, similar to physicians experience enmeshed social, mental, board certification in the United States. Rather US and UK Primary Care Training 163 J Am Board Fam Pract: first published as 10.3122/jabfm.12.2.162 on 1 March 1999. Downloaded from than periodic recertification testing as in the has uniform, comprehensive health coverage free United States, however, general practitioners and at the point of delivery and paid by national taxa directors of postgraduate education are piloting tion, with a small proportion of the population (12 practice-based recertification. Thus, the British percent) having additional, sometimes partial sup approach is to follow Berwick's admonition36 that plemental private insurance, often a perquisite for "the profession

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