Family Practice Vol. 19, No. 3, 219-220
© Oxford University Press 2002
Editorial |
The need for palliative care to remain primary care focused
Community Studies Unit, Whelan Building 2nd floor, University of Liverpool Medical School, Liverpool L69 3GB and
a Barts and the London Queen Mary's School of Medicine and Dentistry, London, UK.
Lloyd-Williams M and Carter Y. The need for palliative care to remain primary care focused. Family Practice 2002; 19: 219–220.
Received 27 July 2001; Revised 28 October 2001; Accepted 7 January 2002.
Palliative medicine is now the eleventh largest medical speciality, but what has happened to the speciality for the holistic care of patients who are dying, which started with its roots firmly in the hospice movement? Patients spend the majority of the last year of life at home under the care of their own GP or family physician.1 In the UK, hospices originally were staffed by experienced GPs who worked a few sessions for the hospice whilst still retaining a role within their own practices. Many of these GPs became medical directors of hospices and provided medical leadership to a new and emerging speciality. During the early days of specialist training in palliative medicine, the doctors who emerged as consultants were often experienced doctors who transferred from other specialities, and a significant number were from a general practice background.
The UK has now seen the emergence of palliative medicine as a medical speciality, and hospices are staffed by consultants and junior medical staff. Although membership of the Royal College of General Practitioners is acceptable for entry to higher specialist training in palliative medicine, an increasing number of specialist registrars are entering specialist palliative medicine training at a much younger age and from a hospital-based background, with little or no primary care or community experience.
Competition for specialist registrar posts in palliative medicine is now intense, and the requirements to enter specialist training may preclude many doctors who have completed vocational training schemes, as they may not have acquired the prerequisite experience of acute hospital medicine to enter higher professional training. Many new consultant posts in palliative medicine are hospital based, with NHS trust contracts. Increasingly, consultants in palliative medicine see themselves as part of the acute services and hospital setting rather than the community setting. Some see this as palliative care becoming detached from what were its community and primary care roots.2 The displacement of palliative care from primary care is not unique to the UK. Primary care doctors in other countries often perceive that palliative care is being removed from the community and into the secondary sector3,4 and, in those countries where there are large rural populations, e.g. Australia and New Zealand, initiatives are taking place to improve the delivery of palliative care by primary care teams.5 In the USA, the difficulty associated with the provision of palliative care within the primary care sector is magnified by the issues of payment for such services.6
It is increasingly apparent that the symptom burden of many patients with chronic life-threatening illnesses is immense and that palliative care should also be extended to these patients.7 Hospices and specialist palliative care units provide specialist palliative care8 which is only required by a relatively small number of patients with difficult physical and psychological symptoms. What the majority of patients require is the palliative care approach from medical and nursing staff who have received basic training in palliative care and understand the principles of symptom control. There are very few posts available in hospices at senior house officer/intern grade.
Where will tomorrow's GPs/family physicians acquire skills in palliative care? In the UK, Macmillan facilitators,9 GPs working in their own practices who spend a fixed number of sessions each week sharing their knowledge and facilitating palliative care in the community, have an important role ensuring that GPs are kept up to date with symptom control and providing practice-based peer teaching and learning.
The NHS Cancer Plan states that by the end of 2004, an extra £50 million will be invested in palliative care. This is both encouraging and puts palliative care on a high and firm agenda. For equity of service and access, it is essential that those who require skills to enable them to provide such care are offered appropriate teaching and training and that palliative care services continue to be integrated into primary care.
Palliative care also needs to recognize that those doctors who have completed vocational training and have a general practice/primary care background have as much to contribute to the speciality as those from an acute hospital-based background.
References
1
Higginson I, Astin P, Dolan S. Where do cancer patients die? Ten year trends in place of death of cancer patients in England. Palliative Med 199812: 353–363.
2
Praill D. Who are we here for? Palliative Med 2000 14: 91–92.
3 Ogle K, Plumb J. The role of the primary care physician in the care of the terminally ill. Clin Geriatr Med 1996 12: 267–278.[Web of Science][Medline]
4 Hunt R, Radford A, Maddocks I et al. The community care of terminally ill patients. Aust Fam Physician 1990 19: 1835–1841.[Medline]
5 Trollor J. Rural general practitioners and palliative care in north-west of New South Wales. Aust Fam Physician 1995 24: 1106–1113.[Medline]
6 Steig R, Lippe P, Shepard T. Roadblocks to effective pain treatment. Med Clin North Am 1999 83: 809–821.[Web of Science][Medline]
7 National Council for Hospice and Specialist Palliative Care. Reaching Out: Specialist Palliative Care for Adults with Non-Malignant Diseases. Occasional Paper 14. London, 1998.
8 National Council for Hospice and Specialist Palliative Care. From Philosophy to Contracts. Occasional Paper 4, London, 1993.
9 CRMF/RCGP Joint Report on Macmillan Facilitator. London, 1995.
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