Family physicians deliver a range of services within preventive patient care. Preventive care is provided on an individual basis, generally in an opportunistic manner. However, it is widely accepted that applying a population-based approach would result in more effective and measurable preventive outcomes, and the community-based approach in primary care is central to the principles of family medicine.public health units and family physicians work ing together could provide a spectrum of primary health care services and health promotion interventions. This paper describes the development of a collaborative working initiative between the two groups and two new programs that have developed. The collaboration should be further explored in primary care reform in Canada.

Enhancing primary care

Each community in Ontario is served by a public health unit, which has a mandate to provide health protection, health promotion, and disease prevention services for all residents in their districts. In 1995 the Hamilton-Wentworth Regional Public Health Department (RPHD), a teaching health unit affiliated with McMaster University in Hamilton, Ont, and the University of Guelph in Ontario, began to examine opportunities for partnering with family physicians. At the same time the Department of Family Medicine at McMaster University had been funded by the Ontario Ministry of Health to develop a primary health care program that, among other priorities, explored how collaborative relationships with public health could enhance primary care.

Both groups believed that primary health care preventive services would benefit from collaboration. Public health and family medicine could work together at two levels: community-wide strategies for promoting the health of communities and family practice-level programs for disease prevention and health promotion. Through discussions, we identified opportunities for collaboration, many building on established work. For family medicine and public health, these include the following:

• undertaking collaborative research projects that incorporate the strengths of each discipline,
• involving family doctors as advisors in commuity development,
• establishing a monitoring and feedback system for family doctors for their prevention interventions,
• applying population indicators to the local populations at risk,
• attaching public health nurses to family medicine group practices to work with disadvantaged groups,
• developing group counseling programs for patients with special needs, and
• supporting the development of patient participation and self-help groups.

Developing and sustaining collaboration

A steering group consisting of RPHD members, McMaster University’s Department of Family Medicine, and community family physicians was set up. Regular meetings and a workshop were held and several key areas of common interest identified. New projects have been developed. These include a heart health research initiative and a public health nurse secondment to family practice.

Heart health. Reducing the risk of heart disease in the community is more likely to be successful through joint efforts of family physicians and public health staff. Family physicians can provide information to patients about preventive behaviours that complement the mass communication, community organization, policy, and environmental support approaches used by public health units. In Ontario information about heart disease prevention is given to patients during office visits and through assessments of communities by epidemiologists and others in public health units.

The Hamilton-Wentworth Heart Health initiative is a community-wide strategic initiative involving many partner agencies. A research subcommittee to enhance heart health in family medicine was set up consisting of public health staff, family physicians, cardiologists, pharmacists, occupational therapists, nutritionists, and geriatricians. The aim of the committee is to improve the health status of seniors in Hamilton-Wentworth through studies that involve a partnership between family medicine, public health, and other specialties.

A pilot project to collect baseline data, involving 16 family physicians, was begun in four clinics: three in Dunneville, Ont (a town adjacent to Hamilton), and one at Stonechurch Family Health Centre (an academic teaching unit of McMaster University’s Department of Family Medicine). Recruitment of patients began in 1998. More than 900 patients older than 65 years entered the study. All patients completed a health questionnaire and received a brief physical examination, including blood testing. Patients have also given the study permission to use their Ontario health cards to assess trends in health care use.

The 16 physicians have received feedback of the current state of health maintenance (eg, blood pressure control, medications, cholesterol) in their patients. Public health staff, family physicians, and other specialists are able to share ideas and develop innovative collaborative interventions to enhance heart health in the elderly.

Public health nurse secondment. The Stonechurch Family Health Centre (Stonechurch) is an academic teaching unit based in the community; it has 10 family physicians and approximately 12 000 registered patients. The Department of Family Medicine and the RPHD have together designed a secondment of a public health nurse at Stonechurch.

In this secondment the public health nurse provides services that include functioning as an office-based primary care nurse; developing and maintaining networks with community agencies; assessing health needs of the practice’s patients and developing programs to meet their needs; advocating on behalf of underserved populations; participating in research; and encouraging involvement of patients and other caregivers in developing services, programs, and policies.

Through formal needs assessments and informal discussion with staff and faculty, the public health nurse role has developed and changed at Stonechurch. She has developed a bereavement counseling program, provided short-term counseling for patients with minor mental health problems, undertaken a regular home visit program for housebound patients, and monitored preventive procedures. In addition, the public health nurse has initiated a “Partners in Health” group composed of patients and their primary care providers. Patients in this group provide direct feedback on needs and services, work collaboratively with staff to produce patient newsletters, and offer information evenings on health-promoting topics of interest. Her position undergoes yearly review and assessment.

Discussion

We have described two initiatives that illustrate some of the mechanisms for integrating primary care and public health to improve the health of local populations.

Since our work began, the Ontario Ministry of Health and the Ontario Medical Association have undertaken a pilot project for primary care reform. Hamilton has been chosen as one of the five pilot sites. Integral to this reform is a new funding formula, enrolling patients on a roster, improving patient access to the primary care system through after-hours coverage and nurse triage, supporting information technology that will capture a core data set, and enhancing disease prevention through new incentive funding. (These funds are restricted, however, to immunization, mammograms, and Pap smears.) New opportunities arise for collaboration between the RPHD and primary care reform sites around data collection and disease prevention. From our 2 year experience, these initiatives could be greatly enhanced if formal structures are set up to encourage participation in these initiatives.

In Britain, new government policy requires that British health authorities (similar to RPHDs) obtain advice from and partner with family practices. This takes the form of pharmacists making educational outreach visits, health promotion facilitators helping practices undertake health promotion, public health physicians assisting with epidemiologic and planning analyses along with computing staff, and centralized administrations offering support for patient registration (rostering) and financial planning. The latest UK National Health Service reforms have placed family medicine at the heart of both public health and health care developments, and a national working group has been set up to explore the shared contributions of public health and primary care. Some community groups have assisted with community needs assessments and implementing primary health care services.

Primary health care reform in Ontario is a priority of both the provincial government and local groups. However, what we have experienced in Hamilton-Wentworth and observed in Britain suggests that, while the public health role of primary care will be determined by policy change, developments could be incremental, building on the skills and structures already present in the community. Our initial attempts in bringing the RPHD and family physicians together in Hamilton to plan and discuss issues have demonstrated the wide-ranging opportunities for improving the health of the public through collaboration and also the skills and enthusiasm of the many stakeholders to take this forward. It is vital that the primary care reforms being proposed support and enhance opportunities for public health integration with family practice populations, and we have shown that the foundations on which to build exist.

Source: Can Fam Physician. 2001 January