Fixing primary care? Create a prevention strategy
Dr. Trevor Hancock
9 July 2019
Last week I proposed that to fix primary care we need to focus on reducing the demand for care, rather than just increasing the supply of care. This requires first of all adopting a ‘whole of government’ and ‘whole of society’ approach, acting beyond the health care system to improve the health of the population and especially to reduce the excess burden of ill health attributable to poverty.
The second component is to create a comprehensive prevention strategy within the health care system, which also has two main elements: Strong and effective public health services and an effective clinical prevention system. Right now, we are weak in both areas in BC, and for that matter across the country, in spite of clear evidence that prevention within the health system should be a priority.
Since I have several times written about the need to strengthen public health services I will not repeat that argument here, other than to note that a 2017 systematic review of 52 studies of the return on investment for public health interventions found that “local and national public health interventions are highly cost-saving”.
Yet despite a 2004 BC Legislature report recommending “Funding for public health activities should gradually increase from about 3 percent of total health expenditure per annum to at least 6 percent per annum”, the Auditor General reported in 2017 that “In 2015/16, health authorities spent $525 million or 4 percent of expenses on population health and wellness services”.
But I want to focus on clinical prevention, which is the set of preventive services you should be getting from your family physician or primary care team. Importantly, this does not include the ‘annual physical’, although many still seem to think it should. But the Canadian Task Force on Preventive Health Care, which was established in 1976 to make recommendations on what works in this important area of primary care, recommended against the annual physical as long ago as 1978.
Reaffirming its recommendation in 2017, the Task Force noted ”routine annual checkups do not offer sufficient health benefits to justify the expense or effort”. Instead, they recommended a “preventive visit with a primary care health professional. . . to provide preventive counseling, immunization, and known effective screening tests”, based on the individual’s specific risks and the appropriate timing for each test.
Happily, we in BC had reached that conclusion several years before. In a 2009 report from the Clinical Prevention Policy Review, which I co-chaired while I was a medical consultant in Population and Public Health at the BC Ministry of Health, we asked and answered the question – ‘what is worth doing in clinical prevention’?
The resulting Lifetime Prevention Schedule (LPS), a first for Canada, is available online. It includes 15 preventive services that meet three criteria: They are clinically effective, would have a significant population health impact if 90 percent of those eligible to receive the service got it, and are cost-effective.
The LPS includes hearing loss screening in newborns, obesity prevention and management in children and youth, and breastfeeding promotion and depression screening for women in the perinatal period. (It does not include prenatal care, which is covered by separate guidelines from Perinatal Services BC or immunizations, which are covered by the BC Immunization Schedule.)
For adults, the Schedule includes a number of services aimed at prevention or early detection of the most common chronic diseases – heart disease, several forms of cancer, alcoholism, diabetes and HIV. The age and frequency of the services is related to age, sex and risk profile.
Our review also posed two other questions: What is the best way to provide the preventive service, and what is the best systematic approach to supporting implementation. The latter includes training for providers, education of the public, an effective information system – including automated reminders for providers and recalls for patients – and proper payments.
However, although a prevention fee for physicians was created, a comprehensive, systematic and well-funded clinical prevention strategy has yet to be implemented, and professional and public awareness and implementation remains low. This is a missed opportunity, one that is cost effective and would have a significant population health impact. It should be addressed as a matter of priority.
© Trevor Hancock, 2019