Policy Bite: Getting the evidence for the impact of family medicine

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Prof Felicity Goodyear-Smith (Chair WONCA Working Party on Research and pictured left) and Prof Amanda Howe (WONCA President) write this month's policy bite.

Last month’s policy bite addressed the value of describing what is happening in different countries, and the launch of a new website which would allow WONCA members to share their country’s data. A different kind of evidence is needed to evaluate the impact of new inputs through primary health care and – in our specific area of interest – family doctors.

One of the real challenges of doing good research and evaluation is the complexity of real life – a new service in one clinic may run very differently from another, because of (for example) better trained staff, a different patient population, or a team that collaborate rather than conflict. In spite of the encouragement of WHO, datasets are often limited, and do not compare like with like (1.) This article outlines the components of a system that need mapping to understand why something new works - or not. And we issue a call for evidence so that we can be aware at the earliest opportunity of new findings which inform WONCA’s advocacy and understanding.

Some of the dimensions that vary in any health system include:

• Who is in the workforce and what they can do – doctors, nurses, health care assistants in primary, secondary or tertiary settings. Increasing the numbers of family doctors or using them in a new way may be an opportunity for a ‘before and after’ study. Similarly, a ‘micro’ study of each attendance – for example, how many issues are addressed in each consultation, how many referrals are made and to whom - may yield useful data on how a generalist family doctor can multitask across multiple needs but reduce hospital attendances

• What the service provides – an extension of a clinical service to include preventive or screening components, or a more systematic approach to chronic disease management will be intended to yield better outcomes – but these need defining and measuring to show whether these aims are achieved

• How the service is financed – overall coverage of the population, services covered, the balance of ‘free at point of use’ versus ‘fee for service’ may all have different impacts

• How the service – both people and infrastructure – is managed, maintained and refreshed

• How the population engage with the service – on a registered list with continuity of care over time, or on an ‘ad hoc’ basis with recurrent choice but little ownership of the relationship

• Who enters and leaves the workforce – including issues of status, recruitment, retention and reward, as well as absolute capacity

• What is counted and coordinated – for quality of care, data and services need to be linked, so that delivery and standards can be monitored over time.

All these can vary in any research study, so we need both to ensure that we describe and measure these different dimensions, and also have indicators that can reflect outcomes when these different components vary. The Primary Health Care Performance Initiative (PHCPI) has prepared a set of ‘Vital Signs’ relevant to primary care,(2) but not all of these relate to the work of family doctors or their teams, and work continues with WHO to explore more robust options that track the impacts of service.

To this end we are putting out a ‘call for evidence’. We are keen to know if anyone is working on studies that explicitly evaluate the role of family doctors within a service. If you are due to publish in the near future, please share your early findings with WONCA leads for your country / regional / globally, so that we can ensure we have the most up to date evidence available. And if you are not a researcher, then please help your academic colleagues as best you can – by collating data, or letting them know of new opportunities to evaluate service developments that involve family doctors.

Together we can make a case for change.

Email your comments to: f.goodyear-smith@auckland.ac.nz

References

1. Measuring quality of health-care services: what is known and where are the gaps? Margaret E Kruk,a Edward Kelley,b Shamsuzzoha B Syed,b Finn Tarp,c Tony Addison c & Yoko Akachic http://www.who.int/bulletin/volumes/95/6/17-195099
2. http://phcperformanceinitiative.org/about-us/our-indicators