Innovation in Family Medicine and Primary Care

July 08, 2014

WONCA President's keynote address to the 2014 WONCA Europe Conference held in Lisbon, Portugal.

Boa tarde queridos amigos.  Good afternoon dear friends.  

As WONCA President, I start by saying thank you.  Thank you to the president of this terrific 19th WONCA Europe Conference, Dr João Sequeira Carlos, to the Organizing Committee Chair, Alexandre Gouveia, to the Scientific Committee chair, Dr Isabel Pereira dos Santos, to the International Advisory Board Chair and WONCA Fellow, Luis Pisco, and to all members of the Portuguese Association of General Practice and Family Medicine. 

And on behalf of all the family doctors from around the world who are here together in Lisbon, my congratulations to Professor Job Metsemakers our WONCA Europe Regional President, to all members of the European Regional Council, and to all our WONCA member organisations in this region, for the great work you are doing together to ensure that all people in Europe have access to a well trained family doctor supported by a great family medicine team. Thank you all for bringing us all together in Lisbon to celebrate family medicine and to share innovations from around the world.

I was walking in Sydney recently and I came across this statue.  It is a bust of Prince Henry the Navigator, a hero of Portugal. Henry was a 15th century Portuguese prince who was responsible for the early development of Portuguese exploration and sponsored the search for new trade routes.  Although Henry’s funded expeditions probably never got as far as Australia, the Portuguese community in Sydney has had a statue erected in his honour as an innovative thinker who changed the world.

The theme of this conference is new routes for general practice and family medicine.  Like Henry the Navigator, we want you to stretch your brains and come up with new ways of thinking about the important work that we do.  I have been asked to focus on the theme of innovation in family medicine and primary care.

Throughout this presentation I want to share with you some of the innovations of the thousands and thousands of family doctors around the world who make up WONCA.  I want to examine some of the changes that are happening and having an impact on the quality and safety of the care that we provide, and on the way we deliver care as family doctors to our patients and our communities.

But I am going to start by sharing with you some wise words about innovation from some famous European philosophers, past and present.

From Michel de Montaigne (1533–1592): “I am disgusted with innovation, in whatever guise, and with reason, for I have seen very harmful effects of it.”

From Voltaire (1694-1778): “Our wretched species is so made that those who walk on the well-trodden path always throw stones at those who are showing a new road.” 

From Edmund Burke (1729–1797): “A spirit of innovation is generally the result of a selfish temper and confined views.”

From Albert Einstein (1879-1955): “We cannot solve a problem by using the same kind of thinking we used when we created them.”

And from contemporary European philosopher, JK Rowling (1965- ):
“Imagination is the uniquely human capacity to envision that which is not, and therefore is the fount of all invention and innovation.”

You can see that some of these wise folk see innovation as a threat, others as a necessity; some as an opportunity, others as being indispensible.  

As family doctors we are great at innovation.  And we have an important contribution to make to the evidence base of medical practice, which comes from our encounters with our patients and our innovations in the work that we do.  WONCA serves to bring our innovative ideas and us together.

In the words of our very first WONCA president, Dr Monty Kent Hughes, speaking to the first WONCA world council in 1972: “the future of our professional discipline will depend on our ability to work together in the service of humanity.”

WONCA brings the family doctors of the world together.  We support the highest standards of clinical care, education, training and research in family medicine.  And we represent family medicine at the World Health Organization (WHO) and ensure that the WHO includes family medicine both in its policy developments and in its roll out of global health programs.  Luisa Pettigrew from the United Kingdom has been doing a wonderful job over this past year as our WHO liaison person.  At this year’s World Health Assembly in Geneva in May, WONCA contributed to the global policy developments of the WHO in many important areas including calling for improvements in access to palliative care through family medicine, and heightening awareness of the role of family doctors in tackling domestic violence, especially against girls and women.

WONCA was started by 18 colleges and academies from around the world.  WONCA now has 118 Member Organisations representing over 500,000 family doctors in 130 countries around the world. 

The 500,000 family doctors represented by WONCA, and including all those of us here, each year have over 2 billion consultations with our patients.  Two billion.  That’s the scope of our current work and our influence.

One of the great innovations of WONCA has been the development of young doctor movements.  You are familiar with the Vasco da Gama Movement established by young family doctors in Europe ten years ago, and we have similar groups in the Asia Pacific, South Asia and South America. Over the last year we have seen the Vasco Da Gama Movement members support the establishment of young family doctor organisations in Africa and the Middle East, and just last month in North America.  Thanks to the innovative thinking and leadership of WONCA Europe’s Vasco Da Gama Movement we now have young doctor movements in every region of the world.

There are those who say that family medicine has no real role to play in low and middle-income countries.   Well we have blown that theory out of the water.  Last year, at our world WONCA conference in Prague, the Director-General of the World Health Organization, Dr Margaret Chan, launched WONCA’s new guidebook on the contribution of family medicine to improving health systems. The guidebook includes a chapter from the WHO showcasing the research into the impact family medicine is having in improving health outcomes in many middle income nations including Brazil, China and Thailand.  And there is a chapter outlining the remarkable work that is underway across Africa to strengthen family medicine, especially involving WONCA member organisations within Africa supporting developments in neighbouring nations.  

One great example is the Primafamed network, which involves family doctors from Ghent in Belgium working with colleagues across sub-Saharan Africa to strengthen primary care and family doctor education and training.

What these developments demonstrate is the need to strengthen the whole health care workforce, including family doctors, community nurses, community health workers, and traditional birthing assistants, and support us working together to deliver appropriate care to all people.  People in low income countries still want and deserve access to health care, access to caring clinicians, access to life saving medications.

We also need to embrace the concept of reverse innovation.  What can health systems in high-income countries learn from the health systems in lower income countries?  It is something that each of us who spends time working in another health system in another country learns very quickly.  

We also need to embrace new technology.  The young doctors with Vasco da Gama have been leading WONCA into the social media age.  I invite you to get on board and join WONCA through Facebook, Twitter and Linked In.

One of great powerhouses of innovation within WONCA is our working party on rural practice.  In April we released the WONCA Rural Medical Education Guidebook, highlighting lessons from around the world on ways to build and support and maintain a highly motivated rural family medicine workforce.  It is available free of charge on the WONCA website. Next year we will hold our WONCA rural conference here in Europe in Dubrovnik in Croatia.

As an aside, one of my favourite chapters in the new WONCA Rural Medical Education Guidebook is from Dr Susan Phillips from Canada.  Susan challenges the stereotype of the rural doctor as a “rugged male”.  Susan did a search of Google images and described her findings.  Susan states, “The typical picture on Google of the family physician and, the rural doctor in particular is the rugged male.”  

I did a Google search and, sure enough, my Google search brought up the same image.  Susan goes on, “Although hardly scientific, a Google search of why doctors choose rural practice unearthed many images of male physicians hiking across fields and forests (often wearing stethoscopes), riding horses, or roasting pigs on a spit. On those rare occasions when women are pictured, they are at work, smiling at children, and wearing those white lab coats most of us abandoned years ago. A recurrent picture is what might be labeled ‘The Big Fish’, not because the doctor gets to be ‘a big fish in a small pond’ (a role some might seek) but because the man pictured (the rural doctor) is holding his catch of the day – a big fish!”

Tomorrow our WONCA working party on environmental health will be launching their new publication on Family Doctors in the Field.  The book contains stories from family doctors from across the globe.  It is available free of charge on the WONCA website.

WONCA takes environmental health seriously.  We are committed to supporting the leadership role family doctors can play as part of the global transformation towards environmental sustainability that must take place over the coming years.
As family doctors we see the direct links between the environment and the health of our patients and our communities every day.  We also appreciate that what is good for the environment is good for our patients’ health, including access to clean water, clean air, fresh locally grown food, and the benefits of physical activity, such as walking and cycling, rather than relying on motorized transportation.  Our work in tackling obesity among our patients can have a positive impact on the environment as well.
As family doctors we also need to lead by example, ensuring that we provide our medical services in an environmentally sustainable manner, conscious of the environmental impact of our family practices. 

As family doctors we know that, in addition to our clinical responsibilities, we have social responsibilities.  We are credible public health advocates and there are times when we need to be vocal for the sake of the health of our communities, to speak out for what is right, to say “this is not OK”.  As family doctors we can be advocates for the health of our planet as well as the health of our patients. 

In another innovation, WONCA has been working with the WHO and the International Commission on Occupational Health looking at the health of workers and their families, especially in developing parts of the world.  We recognise that health and safety are threatened by poor working conditions, which are a daily reality for many workers around the world.  We are also aware of the poor health of many migrant workers based in countries where they have no access to health services.  And we recognize that most health care and preventive services for workers and their families is provided in primary care settings by family doctors like you and me. 

Today WONCA and the International Commission on Occupational Health are launching our joint statement on workers and their families and we pledge “to work with our partner organizations (including the World Health Organization and the International Labour Organisation) to address the gaps in services, research, and policies for the health and safety of workers and to better integrate occupational health in the primary care setting, to the benefit of all workers and their families.”

Our working party on education has developed WONCA’s new global standards for postgraduate family medicine education.  These standards were endorsed by WONCA’s world council at our meeting last year in Prague and provide a benchmark for those developing training programs for family doctors around the world.  On Sunday this week I will be in China with the Director-General of the World Health Organization, Dr Margaret Chan, and together we will be making a presentation to the Shanghai Medical College of Fudan University which is about to become the first Family Medicine Training Program in the world to receive accreditation against the WONCA Global Standards.

I want to take you outside Europe for a few minutes to China. China is one of the countries in the world taking family medicine seriously and it is extraordinary to see the innovations underway in that country.  Some of the innovations underway in the family medicine training program in Shanghai include excellent community-based teaching clinics and clinical simulation laboratories.

Dr Yin Shoulong is a rural general practitioner in Tai Shitun Village in China, who hosted my visit to his clinic earlier this year. Tai Shitun is in the Mi Yun District, two hours drive north of Beijing and a very different world from the densely populated metropolis to the south.

Dr Yin lives in a typical Chinese rural village house built around a central courtyard with his clinic occupying one side of his home.  His patients are from his farming community and many are impoverished and elderly and frail.  Many young people have left the district to seek their fortunes in the big cities to the south.

Dr Yin has devoted his career to supporting the health and well being of the people of his village and the surrounding district.  Recently he has become involved in providing experience in rural medicine to young family medicine trainees on rotation from the Capital Medical University in Beijing.  He is part of the primary care revolution underway across China.

The innovations and reforms underway in China will have implications for the rest of the world, and especially for those countries where family medicine is not yet well established.  China now sees family medicine as the solution to the challenge of providing universal health coverage to their entire population of 1.3 billion people.

The Chinese Government recognizes that one of the biggest challenges is training the family doctor workforce to meet the needs of both urban and rural China. China has embarked on a massive drive to train and recruit up to 400,000 general practitioners in the next seven years in order to reform the country’s health system to meet the current and future needs of the population, especially the 800,000,000 people living in rural areas.  If the challenges can be met with success, then this should provide lessons that will flow to many other parts of the world facing the same challenge of providing universal health coverage. 

China is showing us where we need to innovate in family medicine.  We need innovation in the ways we train a family medicine workforce of doctors and nurses and other health workers to meet each nation’s needs.  We need to find innovative ways to support the existing primary care workforce to upskill.  We don’t want to leave anyone behind.  We need to support innovation in family medicine and primary care research and it is wonderful to see the breadth of academic innovation at this conference as you present your programs and the outcomes of your research to your peers.

Last week I was in Ireland, a country whose government has adopted an innovative national approach to the challenges of primary care by appointing a Minister for Primary Care.  I think this is one innovation all our countries could adopt if they are serious about primary care being the solution to universal health coverage.

One of the countries leading the world in innovations in strengthening family medicine to ensure that health care is available to all people is Brazil.  Brazil is the global leader in addressing universal health coverage through family health teams of doctors, nurses and community health workers.  In November, in one of the favelas, or shantytowns, of Rio de Janeiro, I had the opportunity to visit one of the primary care clinics established to meet the health care needs of the poorest people of that great city. 

At this family medicine clinic I met with young family doctor Euclides Colaço and his colleagues. Euclides works with a family medicine resident, two nurses and six community agents, or community health workers, providing comprehensive clinic-based and home-based care as a team to a defined population of 4,500 people.  

This visit allowed me to see the renowned “Family Health Team” model of Brazil in action. Euclides and showed me a map of the geographic area his team is responsible for. They are expected to know about the health status of every single person living in that area. The community health agents have a key role to play; they go out into the community and visit everybody and bring those in need of assessment and assistance to the clinic, or the community health agents escort the doctor or one of the nurses on a home visit.  This is true comprehensive primary care delivered to an entire community.  And there are over 33,000 such teams in operation across the entirety of Brazil providing care to 200,000,000 people.

Through innovations like these family medicine has the power to transform our world.  The United Nations and the World Health Organization are grappling right now with the challenges of universal health coverage.  You and I know that the solution to universal health coverage is based in primary care and family medicine.

One of the major areas of WONCA’s innovative work has been in mental health.  Our work with the WHO is focusing attention in many countries on ways we can better integrate mental health into family medicine.  I know that the mental health impact of the financial crises and austerity measures have been a major cause of concern for family doctors here in Portugal and across Europe.

Professor Chris Dowrick from The University of Liverpool is a member of our WONCA mental health working party and has described to me how “primary care mental health is being squeezed between a rock and a hard place: in the one hand mental health problems are increasing as a consequence of rising unemployment, poverty and debt; while on the other hand secondary mental health services are being scaled back as a result of government cuts - so primary care is left with an increased burden and reduced specialist support.”

These challenges for our patients also test our own resilience. While we continue to innovate within our practices within our communities to ensure that our patients receive the highest possible standards of care, it is critical that we also continue to innovate to find ways to support each other as well.  

I know how hard you all work as family doctors, that many of you work under very difficult conditions, that the resources that you need to do your job are often not available, that the hours you work and the demands on your time can be arduous, that your resilience is tested regularly.  I know you often feel unappreciated. And you don't often hear the words thank you. This is why WONCA has established the innovation of World Family Doctor Day, held on May 19 each year, to acknowledge the important work that we do.

It was wonderful this May to see the World Family Doctor Day activities underway all around the world celebrating the contributions wonderful family doctors make to the lives of their individual patients and their families and to the health and wellbeing of their communities.  Here are some of the examples from Europe, from Finland, Luxembourg, Macedonia, Romania, Slovakia, Slovenia, Turkey and many others.

So today, on behalf of the 2 billion people around the world who benefited from your care, your innovations and your support over the past year, I say thank you. Thank you for your commitment to being a great family doctor.  And thank you for the important work you do every day providing wonderful health care to the people who trust you for their medical care and advice.  

Thank you. Obrigado.  

Michael Kidd
WONCA President
Lisbon, Portugal
2 July, 2014