Another World

The capital of Kazakhstan, Astana, recently re-named Nur-Sultan, could hardly be further from our preoccupations with Europe and concerns about the NHS. It lies almost 2000 miles east of Moscow. The country’s healthcare system is stretched to breaking point; life expectancy and other health indicators are among the lowest in the world, and the health impacts of the environmental disaster of the Aral Sea are still being felt. Yet this was the location chosen by the World Health Authority for its Global Conference on primary health care last year, and which has given its name to a Declaration on Primary Health Care¹ marking 40 years since the landmark Declaration of Alma-Ata,² which itself affirmed that health is a fundamental human right. It also emphasised that primary health care is an essential component of any health system and included a plea for peace, détente, and disarmament. Our editorial by Sophie Park and Ruth Abrams considers the implications of Astana for the future of health care, and examines some of the ideological and practical tensions within it.

The Declaration is an inspiring read: among other things, it brings home the reality of trying to achieve universal health coverage and effective primary care in environments which are hostile for geopolitical or financial reasons, and also can’t help making you feel extremely grateful for our own good fortune. Among factors that can contribute to the success of the vision are the development of human resources, the use of technology, and the empowerment of individuals and communities. Within the overall theme of teamwork, this issue of the BJGP touches on some important aspects of all three of these, which are not without their own ideological and practical tensions.

Take role substitution and changing skill mix within the primary healthcare team. This is the flavour of the month in many quarters, and we carry a persuasive study by Helen Turner and colleagues on the effectiveness of extended scope physiotherapists acting as first-contact professionals for patients with musculoskeletal problems. Most are managed without the input of GPs, and referrals to secondary care or for investigations are infrequent and appropriate. Yet questions remain, as with many studies like this, of whether the findings are replicable and scalable, or whether they owe much to a happy, local conjunction of opportunity and enthusiasm. Conversely, Bethany Anthony and colleagues’ systematic review of economic evaluations of general medical services provided by non-medical health professionals sounds a warning note and even suggests that some role-substitution may be more expensive than business as usual. Yet many readers will be working in practices which have decided to expand the membership of their primary care teams and have made a success of it.

Technology in primary care is becoming something of a minefield, with a strong political push, lots of provider enthusiasm but real concerns about unintended consequences. Abi Eccles and colleagues’ study of an online triage platform in general practice provides food for thought. Patients seem to use this more or less as they would use a telephone, and for much the same reasons: many patients reported finding it a much preferable alternative, but the authors sound another note of caution and encourage practices to look carefully at exactly what they are trying to achieve by using this new, albeit very simple, technology and how to explain its use to their patients. Once again, I would not be surprised if many readers have moved beyond simple telephone triage and are working with much more sophisticated technologies to improve access, efficiency, and effectiveness. If you are, please let us know! It may well be that collecting examples of excellent practice innovations to provide a range of choices from which other practices can choose and adapt to fit their needs is a more effective way of spreading innovation than waiting for the results of lengthy health services research evaluations. The future is probably here, but is not yet evenly distributed.