1. Review It’s important to define what Primary Care is and the priorities and context in which Primary Care works. After few but important and cornerstone words on Primary Care as in Alma Ata Declaration, we needed a Document defining what General Practice is and its competencies, a really authoritative view on what family doctors in Europe should be providing in the way of services and health to patients, at the highest quality and cost effective. This is not an easy task because of differences in cultural and organizational systems in different Countries. In 1994 Starfield [1] wrote that “primary care is the first – contact, continuous, comprehensive and coordinated care provided to populations undifferentiated by gender, disease or organ system “and wrote about other important issues as cost effectiveness in this field [2]. This definition is very similar, as simple expression, to what we can see as detailed in the European Definition of General Practice / Family Medicine, edited by WONCA Europe at WONCA Congress in London in 2002, and prepared for years by EURACT Council [3]. This Document, approved by all National Colleges of General Practice in Europe, defines at beginning of 21th Century, who a GP is, his/her duties, his/her competencies, his/ her professionalism as a specialist. Reading this document, made with years of work, we could think to be alive and essential as doctors for our patients and health promotion. The approach used is different form that applied in previous documents. If we look at the document of the Leeuwenhorst group [4] or at the Olesen’s definition [5], we see they define the parameters of the discipline by describing the types of tasks that a family doctor has to carry out. It is Bernard Gay’s presentation [6] at the inaugural meeting of WONCA Europe in Strasbourg in 1995, that try to define the fundamental principles of the discipline. Gay suggested a relationship between principles and tasks with some influences on the tasks required from both the patients and the health care system. This should then lead to definitions of competencies which will determine the content. Of course, these tasks are determined to a considerable extent by the health care system in which family doctors work and the changing needs and demands of the patients (older and more demanding). The first international documents (as WHO 1998 and WONCA 1991 and Health for All and Health 21) [7-10] are important, but dealing with professional activity in the health care system, not with the discipline as a medical activity with a specific process. Society has changed over the years and there has been an increasing role for the patient as a determining factor in health care and its provision. Gay’s presentation arrives to speak of “diseases at early stage”, “low prevalence of serious diseases” and “simultaneous management of multiple complaints and pathologies” and these are summarized in the European Definition as “comprehensive care”. This is a crucial aspect of general practice, as a people - based discipline as opposed to pathology or organ - based, and as normality - ori- http://acmcasereports.com/ 2 Volume 6 Issue 17 -2021 Review Article entated as opposed to abnormality - orientation of secondary care; but, at the same time, family doctors meet and manage serious illnesses at an early and undifferentiated stage (with incidence of illness, signs and presentation absolutely specific). Gay considered the disease as the result of organic, human and environmental factors, a concept like the bio psychosocial model of Engel in his “holistic” model [11]. Efficiency is a further statement by Gay which refers to the cost efficiency as a characteristic feature of well developed family health care systems and WONCA Definition indicates that family doctor has a role as resource management in health care systems. But, which is the context in which the family doctor works? It’s different in different Countries, and interfaces and interactions between self-care, primary, secondary and tertiary health care have to be considered because some are putting family doctors as gate keepers, other are not, The necessity for an European Definition came from some strong question like this: what is meant by personal care, is it care by the same doctor on every occasion? if not what are the conditions for a deputy? nobody at EURACT Council felt the GPs should be providing 24 hours personal care, the idea was for providing personal care over a substantial period of time [12]. Also, in Family Medicine, we have that unique relationship between doctor and patient that pushed Balint to coin the term “the drug doctor” [13] and Pereira Gray [14] explored the issue of continuity and the use of time by considering the separate consultations over time as part of a continuum. Advocacy is another point, helping the patient to take an active part in the clinical process and working with the government and other authorities to maximise equitable distribution of services to all members of society. The concept of normality orientation in Primary Care encompasses the activity of promoting health and well – being. McWhinney [15] stressed the organ - based model of biological processes, where we have to take in mind history, context and environment. The European Definition is taking strong consideration of the community orientation. This is because family doctors have a responsibility for the community in which they work and must understand the potentials and limitations of the community. As in all societies health care systems are being rationed and doctors are involved in the rationing decisions, also ethical and moral responsibilities are on GPs’ shoulders and they could try to influence health policy in the community. How? I think it could be reconciling the health needs of individual patients and of the community in balance with really available resources. To do this, I’d say that GPs have to be allowed contractually to act as advocates for their patients and for community health promotion. To be able to act in this way, they need to learn in the basic curriculum and in the Vocational Training the interrelationships between health and social care, the impact of poverty, ethnicity, inequalities, the structure of the health care system in which they live and in which they work. How to learn this? With case – discussions, record reviews, visiting health and social care institutions, making audit of practice, as indicated in the Educational Agenda [16]. As discussed in a debate about interpretation of the European Definition, [17] this one is, as all political documents, an indication, a way, to be integrated in each Country’s reality. Answering to a question specifically made by an Italian GPs Society concerning continuity of care, I discussed with EURACT Council, arriving to conclude that documents are strategic, and should be applied to a country specific situation, that is different in every country. That means that flexibility is necessary in order to avoid mismatches with local legislation acts and overall situation in health care system. What is obvious in one country, maybe not appropriate in another. The question is not that much interpretation, but rather application and implementation. Again, if we want to promote health and well being by applying health promotion and disease prevention strategies appropriately, we could use a comprehensive approach. This is often in contrast with the specialist approach in treating as many medical problems as possible. My job in my practice is to handle risk factors promoting self – care and to limit or minimise the impact of my patients’ symptoms and reactions on their well being by taking into account their personalities, families, daily life, physical and social surroundings, and, also, their backgrounds, cultural and religious believes. I would like to stress that for teaching and learning health promotion, it’s mandatory an early exposure to clinical experiences within the primary care setting and this is one of the new task for development in the EURACT BME Committee. A comprehensive approach as I’m describing is not far the holistic module Gay described and the European Definition indicates as one of the six core competencies for family doctors. Considering holistic as the bio – psycho – social model, it could useful focalise on health. It is focalising on health beliefs and life experiences that makes a person the entity that it is now; the health – maintaining factors in a person, like the understanding of events, the acceptance of meaning, the autonomy that leads to the conviction that life is manageable.
References1. Starfield B. Is Primary Care Essential. The Lancet, 1994; Vol. 344: 1129-1132.
2. Starfield B. Primary care: balancing health needs, services and technology. Oxford: Oxford University Press, 1998.
3. The European Definition of General Practice/Family Medicine, WONCA Europe, London, 2002.
4. The General Practitioner in Europe: A statement by the working party appointed by the European Conference on the Teaching of General Practice, Leeuwenhorst, Netherlands 1974.
5. Olesen F, Dickinson J, Hjortdahl P. General Practice – time for a new definition BMJ. 2000; 320: 354-357.
6. Gay Bernard. What are the basic principles to define general practice. Presentation to Inaugural Meeting of European Society of General Practice/Family Medicine, Strasbourg, 1995.
7. Framework for Professional and Administrative Development of General Practice/Family Medicine in Europe, WHO Europe, Copenhagen, 1998.
8. The role of the General Practitioner / Family Physician in Health Care Systems: a statement from WONCA, 1991.
9. Global Strategy for Health for All by the Year 2000, 1985.
10. WHO Euro-Region 21 Targets for Health 21, 1997.
11. Engel GL, The clinical application of the biopsychosocial model. Am. J. Psychiatry, 1980. 137 (5):535-44.
12. EURACT Council Report from Eger (Hungary), April 2001. Personal documents.
13. Balint M. The Doctor, his Patient and the Illness. Pittman Medical, London, 1964.
14. Pereira Gray D. Forty-seven minutes a year for the patient. British J. Gen. Pract., 1998; (437):1816-1817.
15. McWhinney Ian R. The importance of being different. British J. Gen. Pract: 1996; 46: 433-436.
16. Heyrman J. and EURACT Council – The Educational Agenda of General Practice/Family Medicine – Leuven, 2004.
17. Carelli F. European Definition and contracts – 2002, m.d.-Medicinae Doctor; 34: 10-11.
Carelli F .The Nature of Primary Care . Annals of Clinical and Medical Case Reports 2021