- Email: [email protected]
Making primary care people-centred
Correspondence
We declare no competing interests. The authors alone are responsible for the content of this paper, which might not necessarily represent the policies, decisions, or views of WHO. © 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
Colleen D Acosta, Dorit N Kaluski, *Masoud Dara [email protected] Tuberculosis and M/XDR-TB Control Programme, Division of Communicable Diseases, Health Security and Environment, WHO Regional Office for Europe, DK-2100 Copenhagen, Denmark (CDA, MD); and WHO Country Office, Ukraine, Borychiv Tik, Kiev, Ukraine (DNK) 1
2 3
4
5
6
Office of the United Nations High Commissioner for Human Rights. Report on the human rights situation in Ukraine, Aug 17, 2014. http://www.ohchr.org/ Documents/Countries/UA/ UkraineReport28August2014.pdf (accessed Sept 10, 2014). Holt E. Ukraine: health workers fear for their safety. Lancet 2014; 384: 735. European Centre for Disease Prevention and Control, World Health Organization Regional Office for Europe. Surveillance report: tuberculosis surveillance and monitoring in Europe, 2014. http://www.ecdc.europa.eu/en/ publications/Publications/tuberculosissurveillance-monitoring-Europe-2014.pdf (accessed Sept 10, 2014). Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Soc Sci Med 2009; 68: 2240–46. Verver S, Bwire R, Borgdorff MW. Screening for pulmonary tuberculosis among immigrants: estimated effect on severity of disease and duration of infectiousness. Int J Tuberc Lung Dis 2001; 5: 419–25. Dara M, de Colombani P, Petrova-Benedict R, et al. The minimum package for cross-border TB control and care in the WHO European region: a Wolfheze consensus statement. Eur Respir J 2012; 40: 1081–90.
Making primary care people-centred The Lancet Editorial (July 26, p 281)1 commented on the recently released report by an independent expert www.thelancet.com Vol 384 October 25, 2014
panel of the European Commission on how a primary care system should operate in the 21st century. While the Editorial agreed with the report’s diagnosis of what is wrong with primary care in most high-income countries and what needs to be fixed, your suggested solution did not. By placing the blame on primary care leadership to explain why primary care remains fragmented, ineffective, and plagued with accessibility problems, the Editorial perpetuates the myth that most resistance to change comes from within the primary care community itself. We all want primary care that is fair, equitable, accessible, cost effective, and sustainable. Unfortunately, as a society, we are not willing to pay for it. The type of revolution envisioned by the European Commission’s report, while both timely and appropriate, requires a complete shift in terms of resource allocation and priority setting, which most high-income countries are not prepared to carry out. As long as this remains the case, primary care is not likely to live up to its full potential as the most important pillar for people-centred health and wellbeing in the 21st century. A blueprint, even the best one, without a corresponding investment is just a blueprint. I declare no competing interests.
Janusz Kaczorowski [email protected] University of Montreal Hospital Research Centre (CRCHUM), Université de Montréal, Montreal, QC H2X 0A9, Canada 1
The Lancet. Making primary care people-centred: a 21st century blueprint. Lancet 2014; 384: 281.
In their Editorial, “Making primary care people-centred: a 21st century blueprint”, The Lancet editors issued a clarion call for the merging of primary care with elements of secondary care, to form a streamlined community service that meets most patients’ needs locally.1 This radical
proposal entails a more tractable hospital component, and a robust electronic recording system to coordinate a collaborative service involving disparate professionals who would otherwise be isolated from each other. Health care evolves continuously, sometimes with unintended consequences. Even while medical interventions become increasingly pervasive and invasive, sustained patient–doctor relationships become rarer because of logistic pressures. This undermining of continuity jeopardises the quality of medical care, and patients’ confidence in the profession. Increasingly, the vision of the Royal College of Physicians’ working party on professionalism— that a doctor’s purpose is realised through a partnership based on mutual respect, individual responsibility, and appropriate accountability—becomes more tenuous.2 The proposed multi-agency community service would, in the place of worthy but ultimately banal mission statements, benefit from a comprehensive explicit ethos that binds multiple disparate health professionals into a high quality cross-discipline shared endeavour, and reassures patients that their best interests are prioritised. UN General Comment 14, the Magna Carta of health rights published in 2000, exhaustively and authoritatively defines patients’ health rights and their ethical implementation using human rights principles.3 The value of such an ethos lies in its foundation in law, universality, conceptual practicality, aspirational appeal, comprehensiveness, and above all, ownership of its constituent parts by the people.
Larry Williams/Corbis
be scaled up to provide adequate management of close contacts of people with tuberculosis, increase availability of rapid diagnostic tests for MDR-tuberculosis, and ensure access for migrant communities to effective treatment for all forms of the disease. Such measures are crucial if the tuberculosis and MDR-tuberculosis situation is to be controlled.
I was involved in the creation, drafting, writing, and ratification of UN General Comment 14.
Peter Hall [email protected] Doctors for Human Rights, Watford WD5 0BE, UK
For more on the European Commission report see http:// ec.europa.eu/health/expert_ panel/opinions/docs/004_ definitionprimarycare_en.pdf
1501
Correspondence
1
The Lancet. Making primary care people-centred: a 21st century blueprint. Lancet 2014; 384: 281. Working Party of the Royal College of Physicians. Doctors in society: medical professionalism in a changing world. Clin Med 2005; 5 (6 suppl 1): S15. UN. Substantive issues arising in the implementation of the International Covenant on Economic, Social and Cultural Rights. General comment No. 14 (2000). The right to the highest attainable standard of health (article 12 of the International Covenant on Economic, Social and Cultural Rights). Geneva: United Nations, 2000. http://tbinternet.ohchr. org/_layouts/treatybodyexternal/Download.as px?symbolno=E%2FC.12%2F2000%2F4&Lang =en (accessed July 31, 2014).
2
3
Alteplase for ischaemic stroke Roger Shinton’s Correspondence (Aug 23, p 659)1 called into question the evidence supporting the safe use of alteplase in patients with acute ischaemic stroke.1 Ian Hudson, of the Medicines and Healthcare Products Regulatory Agency (MHRA), responded to this Correspondence by convening an expert working group to review the benefits and risks of this drug.2 A review of reports of spontaneous adverse drug reactions (ADR) should inform this query, but a substantial level of under-reporting might restrict its use. Symptomatic intracerebral haemorrhage (ICH) represents the major adverse reaction of alteplase in acute stroke and is well documented in
trials. Results from a meta-analysis3 of thrombolysis showed a symptomatic ICH rate of 7·5% in the thrombolysis group compared with 1·7% in the control group. In the UK, the proportion of all patients with stroke given thrombolysis increased from 1·8% to 11% during the past 5 years.4 The present rate of symptomatic ICH is 4% but yearly reports for all suspected ADRs for alteplase do not show this (figure). On the basis of UK audit data from 2013 to 2014,4 more than 300 patients developed symptomatic ICH after thrombolysis. However, since the licensing of alteplase in the UK in 1988, until August, 2014, only 102 CNS haemorrhages and cerebrovascular accidents have been reported to the MHRA.5 All serious, suspected ADRs for drugs with established uses should be reported to the MHRA. The level of under-reporting of spontaneous suspected ADRs is unknown; nonetheless, these data provide information for the safe use of drugs.6 Spontaneous reporting of ADRs for alteplase is inadequate. Monitoring of drug safety needs promoting, particularly if the balance of benefits versus risks is controversial. I thank Tahira Jan (MHRA, London, UK) for providing MHRA data used for the figure. I declare no competing interests.
45 40
Number of reports
35 30 25 20 15 10 5
19 89 19 90 19 9 19 1 92 19 9 19 3 94 19 9 19 5 96 19 9 19 7 98 19 99 20 00 20 0 20 1 02 20 0 20 3 04 20 05 20 06 20 0 20 7 08 20 09 20 10 20 1 20 1 1 20 2 13
0 Year
Figure: Yearly suspected spontaneous UK adverse drug reaction reports for alteplase received by MHRA
1502
Daniel Burrage [email protected] Clinical Pharmacology Unit, Institute of Infection and Immunity, St George’s University of London, London SW17 0RE, UK 1
2 3
4
5
6
Shinton R. Questions about authorisation of alteplase for ischaemic stroke. Lancet 2014; 384: 659–60. Hudson I. Alteplase for ischaemic stroke: responses. Lancet 2014; 384: 662–63. Wardlaw JM, Murray V, Berge E, del Zoppo GJ. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2014; 7: CD000213. Intercollegiate Stroke Working Party, Royal College of Physicians. Sentinel Stroke National Audit Programme (SSNAP): clinical audit January–March 2014 public report. https:// www.strokeaudit.org/results/national-results. aspx (accessed Oct 2, 2014). Medicines and Healthcare Products Regulatory Agency. Drug analysis print drug name: alteplase. https://www.strokeaudit.org/ Documents/Latest-Results/Jan-Mar-2014Results/National/SSNAP-Public-Report(January-March-2014)-Not-for-C.aspx (accessed Oct 2, 2014). Hazell L, Shakir SA. Under-reporting of adverse drug reactions. Drug Saf 2006; 29: 385–96.
Cancer in the 25×25 non-communicable disease targets Vasilis Kontis and colleagues in their study (Aug 2, p 427)1 provided much needed estimates of the potential to lower premature mortality of four main non-communicable diseases (NCDs) by addressing six risk factors. These factors are part of a larger set of targets and indicators defined in WHO’s NCD Global Monitoring Framework 2 (GMF) to meet the 25×25 goals. Although Kontis and colleagues1 estimated a mortality reduction of around 20% in men and women for the four NCDs, estimates for individual NCDs varied substantially. We are struck by the projected reduction of just 7% in premature deaths from cancer by comparison with 34% for all cardiovascular diseases, with the cancer contribution to premature NCD deaths predicted to reach 39·2% by 2025. Clearly for cancer more interventions are needed. www.thelancet.com Vol 384 October 25, 2014
We declare no competing interests. The authors alone are responsible for the content of this paper, which might not necessarily represent the policies, decisions, or views of WHO. © 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
Colleen D Acosta, Dorit N Kaluski, *Masoud Dara [email protected] Tuberculosis and M/XDR-TB Control Programme, Division of Communicable Diseases, Health Security and Environment, WHO Regional Office for Europe, DK-2100 Copenhagen, Denmark (CDA, MD); and WHO Country Office, Ukraine, Borychiv Tik, Kiev, Ukraine (DNK) 1
2 3
4
5
6
Office of the United Nations High Commissioner for Human Rights. Report on the human rights situation in Ukraine, Aug 17, 2014. http://www.ohchr.org/ Documents/Countries/UA/ UkraineReport28August2014.pdf (accessed Sept 10, 2014). Holt E. Ukraine: health workers fear for their safety. Lancet 2014; 384: 735. European Centre for Disease Prevention and Control, World Health Organization Regional Office for Europe. Surveillance report: tuberculosis surveillance and monitoring in Europe, 2014. http://www.ecdc.europa.eu/en/ publications/Publications/tuberculosissurveillance-monitoring-Europe-2014.pdf (accessed Sept 10, 2014). Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Soc Sci Med 2009; 68: 2240–46. Verver S, Bwire R, Borgdorff MW. Screening for pulmonary tuberculosis among immigrants: estimated effect on severity of disease and duration of infectiousness. Int J Tuberc Lung Dis 2001; 5: 419–25. Dara M, de Colombani P, Petrova-Benedict R, et al. The minimum package for cross-border TB control and care in the WHO European region: a Wolfheze consensus statement. Eur Respir J 2012; 40: 1081–90.
Making primary care people-centred The Lancet Editorial (July 26, p 281)1 commented on the recently released report by an independent expert www.thelancet.com Vol 384 October 25, 2014
panel of the European Commission on how a primary care system should operate in the 21st century. While the Editorial agreed with the report’s diagnosis of what is wrong with primary care in most high-income countries and what needs to be fixed, your suggested solution did not. By placing the blame on primary care leadership to explain why primary care remains fragmented, ineffective, and plagued with accessibility problems, the Editorial perpetuates the myth that most resistance to change comes from within the primary care community itself. We all want primary care that is fair, equitable, accessible, cost effective, and sustainable. Unfortunately, as a society, we are not willing to pay for it. The type of revolution envisioned by the European Commission’s report, while both timely and appropriate, requires a complete shift in terms of resource allocation and priority setting, which most high-income countries are not prepared to carry out. As long as this remains the case, primary care is not likely to live up to its full potential as the most important pillar for people-centred health and wellbeing in the 21st century. A blueprint, even the best one, without a corresponding investment is just a blueprint. I declare no competing interests.
Janusz Kaczorowski [email protected] University of Montreal Hospital Research Centre (CRCHUM), Université de Montréal, Montreal, QC H2X 0A9, Canada 1
The Lancet. Making primary care people-centred: a 21st century blueprint. Lancet 2014; 384: 281.
In their Editorial, “Making primary care people-centred: a 21st century blueprint”, The Lancet editors issued a clarion call for the merging of primary care with elements of secondary care, to form a streamlined community service that meets most patients’ needs locally.1 This radical
proposal entails a more tractable hospital component, and a robust electronic recording system to coordinate a collaborative service involving disparate professionals who would otherwise be isolated from each other. Health care evolves continuously, sometimes with unintended consequences. Even while medical interventions become increasingly pervasive and invasive, sustained patient–doctor relationships become rarer because of logistic pressures. This undermining of continuity jeopardises the quality of medical care, and patients’ confidence in the profession. Increasingly, the vision of the Royal College of Physicians’ working party on professionalism— that a doctor’s purpose is realised through a partnership based on mutual respect, individual responsibility, and appropriate accountability—becomes more tenuous.2 The proposed multi-agency community service would, in the place of worthy but ultimately banal mission statements, benefit from a comprehensive explicit ethos that binds multiple disparate health professionals into a high quality cross-discipline shared endeavour, and reassures patients that their best interests are prioritised. UN General Comment 14, the Magna Carta of health rights published in 2000, exhaustively and authoritatively defines patients’ health rights and their ethical implementation using human rights principles.3 The value of such an ethos lies in its foundation in law, universality, conceptual practicality, aspirational appeal, comprehensiveness, and above all, ownership of its constituent parts by the people.
Larry Williams/Corbis
be scaled up to provide adequate management of close contacts of people with tuberculosis, increase availability of rapid diagnostic tests for MDR-tuberculosis, and ensure access for migrant communities to effective treatment for all forms of the disease. Such measures are crucial if the tuberculosis and MDR-tuberculosis situation is to be controlled.
I was involved in the creation, drafting, writing, and ratification of UN General Comment 14.
Peter Hall [email protected] Doctors for Human Rights, Watford WD5 0BE, UK
For more on the European Commission report see http:// ec.europa.eu/health/expert_ panel/opinions/docs/004_ definitionprimarycare_en.pdf
1501
Correspondence
1
The Lancet. Making primary care people-centred: a 21st century blueprint. Lancet 2014; 384: 281. Working Party of the Royal College of Physicians. Doctors in society: medical professionalism in a changing world. Clin Med 2005; 5 (6 suppl 1): S15. UN. Substantive issues arising in the implementation of the International Covenant on Economic, Social and Cultural Rights. General comment No. 14 (2000). The right to the highest attainable standard of health (article 12 of the International Covenant on Economic, Social and Cultural Rights). Geneva: United Nations, 2000. http://tbinternet.ohchr. org/_layouts/treatybodyexternal/Download.as px?symbolno=E%2FC.12%2F2000%2F4&Lang =en (accessed July 31, 2014).
2
3
Alteplase for ischaemic stroke Roger Shinton’s Correspondence (Aug 23, p 659)1 called into question the evidence supporting the safe use of alteplase in patients with acute ischaemic stroke.1 Ian Hudson, of the Medicines and Healthcare Products Regulatory Agency (MHRA), responded to this Correspondence by convening an expert working group to review the benefits and risks of this drug.2 A review of reports of spontaneous adverse drug reactions (ADR) should inform this query, but a substantial level of under-reporting might restrict its use. Symptomatic intracerebral haemorrhage (ICH) represents the major adverse reaction of alteplase in acute stroke and is well documented in
trials. Results from a meta-analysis3 of thrombolysis showed a symptomatic ICH rate of 7·5% in the thrombolysis group compared with 1·7% in the control group. In the UK, the proportion of all patients with stroke given thrombolysis increased from 1·8% to 11% during the past 5 years.4 The present rate of symptomatic ICH is 4% but yearly reports for all suspected ADRs for alteplase do not show this (figure). On the basis of UK audit data from 2013 to 2014,4 more than 300 patients developed symptomatic ICH after thrombolysis. However, since the licensing of alteplase in the UK in 1988, until August, 2014, only 102 CNS haemorrhages and cerebrovascular accidents have been reported to the MHRA.5 All serious, suspected ADRs for drugs with established uses should be reported to the MHRA. The level of under-reporting of spontaneous suspected ADRs is unknown; nonetheless, these data provide information for the safe use of drugs.6 Spontaneous reporting of ADRs for alteplase is inadequate. Monitoring of drug safety needs promoting, particularly if the balance of benefits versus risks is controversial. I thank Tahira Jan (MHRA, London, UK) for providing MHRA data used for the figure. I declare no competing interests.
45 40
Number of reports
35 30 25 20 15 10 5
19 89 19 90 19 9 19 1 92 19 9 19 3 94 19 9 19 5 96 19 9 19 7 98 19 99 20 00 20 0 20 1 02 20 0 20 3 04 20 05 20 06 20 0 20 7 08 20 09 20 10 20 1 20 1 1 20 2 13
0 Year
Figure: Yearly suspected spontaneous UK adverse drug reaction reports for alteplase received by MHRA
1502
Daniel Burrage [email protected] Clinical Pharmacology Unit, Institute of Infection and Immunity, St George’s University of London, London SW17 0RE, UK 1
2 3
4
5
6
Shinton R. Questions about authorisation of alteplase for ischaemic stroke. Lancet 2014; 384: 659–60. Hudson I. Alteplase for ischaemic stroke: responses. Lancet 2014; 384: 662–63. Wardlaw JM, Murray V, Berge E, del Zoppo GJ. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2014; 7: CD000213. Intercollegiate Stroke Working Party, Royal College of Physicians. Sentinel Stroke National Audit Programme (SSNAP): clinical audit January–March 2014 public report. https:// www.strokeaudit.org/results/national-results. aspx (accessed Oct 2, 2014). Medicines and Healthcare Products Regulatory Agency. Drug analysis print drug name: alteplase. https://www.strokeaudit.org/ Documents/Latest-Results/Jan-Mar-2014Results/National/SSNAP-Public-Report(January-March-2014)-Not-for-C.aspx (accessed Oct 2, 2014). Hazell L, Shakir SA. Under-reporting of adverse drug reactions. Drug Saf 2006; 29: 385–96.
Cancer in the 25×25 non-communicable disease targets Vasilis Kontis and colleagues in their study (Aug 2, p 427)1 provided much needed estimates of the potential to lower premature mortality of four main non-communicable diseases (NCDs) by addressing six risk factors. These factors are part of a larger set of targets and indicators defined in WHO’s NCD Global Monitoring Framework 2 (GMF) to meet the 25×25 goals. Although Kontis and colleagues1 estimated a mortality reduction of around 20% in men and women for the four NCDs, estimates for individual NCDs varied substantially. We are struck by the projected reduction of just 7% in premature deaths from cancer by comparison with 34% for all cardiovascular diseases, with the cancer contribution to premature NCD deaths predicted to reach 39·2% by 2025. Clearly for cancer more interventions are needed. www.thelancet.com Vol 384 October 25, 2014