1 The Role of General Practitioners in preventing disease and promoting health in the Nordic countries Nordic general practice - Policy Document Health is not only the absence of illness and disease. Health is a resource that enables each individual to build and live a fulfilled life, and it is also a resource for our society to develop and prosper. This is a fundamental principle supported by Nordic general practice in line with principles such as peace, social justice and equity. Nordic general practice seeks to inspire governments and local authorities to promote health and to focus on preventive health care as an important aspect of all areas of legislation and administration. Preventive health care comprises decisions and measures in all sections of society and involves a variety of professions. General Practitioners play a major role in preventive health care, both in setting the terms as well as putting them into practice. Nordic general practice aims to prevent premature death and reduce health discrepancies in society. This document presents a vision for how general Practitioners can and should approach and contribute to attaining these goals. This document also provides recommendations of strategies and approaches for authorities to implement at the national, regional and local level. The medical report Fair Society, Healthy Lives by Michael Marmot and colleagues 1 has been of the primary sources of inspiration for the fundamental ideas expressed in this document. Nordic general practice seeks to signify the importance of scientific and ethical dilemmas related to preventive health care. The principles of Nordic general practice are: Social initiatives and strategies that are aimed at the general population should be prioritized over individual and disease-specific preventive strategies General Practitioners should take an active part in preventive health care and in professional developments in the field, and also convey their knowledge to relevant working partners General practice must be designed and organized in a way that inspires doctors to discuss relevant preventive measures with their patients General Practitioners must be capable of communicating knowledge-based advice, which promotes health and prevents disease accordingly to the individual patient When assessing disease risk in general it is important to include all the relevant factors that might affect the individual: biological constitution, personal life history, family relations and lifestyle. Many complex and prevalent diseases have common roots and tend to cluster within the same patients (co- and multi-morbidity). Such accumulation of illness can best be prevented by influencing underlying causal factors for example social deprivation or destructive relationships 1
2 Influencing life choices with a preventive approach constitutes a pedagogical and ethical challenge and requires caution. Assessments of health issues should be made with respect for the personal life situation and values of each individual patient. General practitioners must develop an awareness of golden moments when conditions for successful preventive counselling are particularly suitable Knowledge base Poor living conditions and lack of social support combined are the factors that have the greatest negative effect on people s health throughout the life course. By statistical measures, the higher up social ladder, the better the health. This is one of the greatest challenges facing the welfare state, and it represents a huge challenge in preventive health care in the general practice. Recent years research in the field of medicine and associated disciplines has contributed to a far deeper understanding of the fundamental connections between conditions of daily life and health. The new knowledge substantiate the importance of including individual living conditions as well as socio-cultural, relational, and personal aspects in the consideration of the health of the individual patient. General practitioners are particularly well positioned to contribute to goaloriented preventive efforts in relation to individuals. This indicates that knowledge-based family medicine covers a wide area in health care. On the one hand, the knowledge base must contain general medical knowledge with relevance for people in general. This includes evidence-based medicine (EBM), founded on intervention studies and epidemiological analyses. On the other hand, general practitioners are able to gain individual knowledge of the person over time, including personal relations, living conditions, life situation, and personal values, which is also of great importance and should be acknowledged. Currently general Practitioners are subjected to the expectation that they should be able to assess health risks and intervene at an early stage in order to prevent future illness. Strict requirements must be set regarding the documentation and the assessment of relevance of such pro-active preventive activities, and potential side effects must always be anticipated and monitored. An open discussion is a prerequisite for optimal professional development in this field. The scope of measures aimed at subjectively healthy people must be prioritized and adapted to other duties and tasks of the general practitioners. Recommended Strategies At the national level, preventive health care measures are implemented through political initiatives, requirements from authorities, national strategies, health programs and campaigns, which influence all sectors of society. It is well documented that good relationships are crucial for the health of an individual. It is fundamental that the nature of a society is one in which people in general are treated with respect and thereby facilitate the development of a healthy self-respect. Competent policies with regard to schools, kindergartens, family, and integration are therefore of fundamental significance. One of the most significant preventive measures is to ensure that every child grows up in a secure environment in the presence of responsible adults. National strategies to reduce the consumption of tobacco, alcohol and other intoxicating substances are important. Likewise, initiatives that encourage more physical activity and other preventive measures aimed at preventing harmful obesity are important as well. Such strategies must be based on the acknowledgement that the foundation of habits, which might be adverse to a good health, are often laid early in a person s life under the influence of conditions external to the individual in question.
3 The importance of national child vaccination programs is emphasized. Screening programs for cancer are currently the object of the international debate. The evidence base for each program must be regularly assessed. Information to the public must be open and balanced with regard to both benefits and potential harmful effects. Documented effects and side effects must be presented in absolute figures and with the same denominator so that numbers relating to benefits and harms can be easily compared. At the regional and local levels, preventive care is implemented in the form of interdisciplinary public health initiatives. Municipalities and county authorities are responsible for creating a health-promoting local environment, for making it easier to make healthy choices, and for facilitating relevant group-oriented measures that both promotes health and prevent illness, and makes information about these initiatives available. General practitioners are responsible for acquainting themselves with regional and local healthpromoting activities in order to be able to give relevant and practical advice specifically tailored to the individual. Local committees of general practitioners and local liaison committees between the general practitioners and local, municipal authorities can be useful arenas for exchanging points of view and knowledge in this field. General practitioners are encouraged to participate actively in local, public health work. At the individual level, information, counselling, and guidance must be adapted to and anchored in the resources and vitality of the individual. Any preventive initiative must be considered in the light of the fact that good relationships with family, friends and colleagues, as well as meaningful work and appropriate integration into society, are essential for the health of the individual. An important task of general practitioners is to support individuals in taking good care of themselves and those who are close to them, in limiting their consumption of tobacco, alcohol and other intoxicating substances, and also in encouraging them to be physically active and eat healthy food. Individuals who are already sick and people who have, or can be expected to have a significantly increased risk of future disease should have free, easy and good access to their general practitioners. The general practitioners should be particularly observant to people who have experienced or are experiencing adverse life events, including trauma, neglect and violations such as violence or abuse. People who are in demanding situations as caregivers, or struggle with drug or alcohol problems, or severe mental disorder and strain also have an increased risk of contracting other diseases. This also applies to individuals who are out of work or who for other reasons have lost or are losing control of their own lives. It is important to be especially attentive towards children of seriously ill or poorly functioning parents or siblings. Children (from the time of their conception) and pregnant women are particularly vulnerable groups. Clinic guidelines for the prevention of specific diseases may constitute a useful aid. Clinic guidelines targeted on general practice should be available in all areas of importance. It is necessary that general practitioners are acquainted with these guidelines while also recognizing their methodological strengths and weaknesses. Official disease-specific guidelines are generally based on statistical average estimates with limited validity for any given individual. Recommended threshold values for risk intervention are not based medical facts alone, but stem
4 from consensus founded on research-based data and subjective value choices. Also, the consensus processes are often influenced by the pharmaceutical industry and by professional circles focusing heavily on biological measurements and the use of medication, which should be taken into consideration when applying guidelines on the individual level. Guidelines should be revised regularly. Risk detection and intervention do not always benefit health. If a measure is not regarded as relevant and realistic, the individual may experience concern and powerlessness as a result. A strong and selective focus on risk factors alone may result in that the doctor and the patient fail to attend to more basic matters that are of greater significance for the life and health of the person in question. The total sum of recommended interventions creates considerable practical problems and ethical dilemmas. This is partly caused by the fact that the threshold values for intervention are decreasing while the number of diseases covered by guidelines is increasing. If all the recommended initiatives are put into practice, large sections of the population may well change their status from being healthy to being at risk. We know that good self-assessed health is a significant prognosis factor in itself. The diagnosis of risk conditions and everyday ailments as illnesses is not to be recommended. Nordic general practice opposes communicative or educational aids that can be expected to offend or stigmatise vulnerable patients. Experiences in which fear is combined with powerlessness or shame can themselves harm the individual s health. Treating healthy people with drugs aimed at preventing illness needs particular awareness. The requirements for documenting the long-term effects and side effects of medication that are to be used by healthy people should be even stricter than for curative drugs used by diseased people. The professional environment must pay more attention to the risks linked to preventive multi-drug treatment particularly for elderly and old people. General practitioners should be aware of WHO s criteria for screening and should realize that comprehensive medical check-ups of healthy people rarely represent a rational and acceptable use of resources. Health is not only the absence of illness and disease. It is also a resource for each person to build and fulfil his or her life, and a resource for society to develop and prosper.
5 Marit Hermansen President of the Norwegian College of General Practice Kari Sollien President of the Norwegian Union of General Practitioners Karin Träff Nordström President of the Swedish College of General Practice Ove Andersson President of the Swedish Union of General Practitioners Þórarinn Ingólfsson President of the Icelandic College of General Practitioners Pekka Honkanen President of the Finnish College of General Practice Arto Virtanen President of the Finnish Union of General Practitioners Lars Gehlert Johansen President of the Danish College of General Practitioners Bruno Melgaard Jensen President of the Danish Union of General Practitioners
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