Across the spectrum of primary health: from rainbow health to end-of-life care

This issue starts with a thoughtful editorial from Emeritus Professor Richard Baker from Leicester, who identifies the role of primary health care in reducing inequalities and the burden of multimorbidity in an aging population.¹ Services which provide comprehensive clinical care, a public health perspective, have equality of access, and a therapeutic relationship lead to increased life expectancy of disadvantaged populations. The role primary health care plays in reducing mortality should not be under-estimated.

A viewpoint article by Kathleen Potter explores how both the quality of life and the quality of death in the elderly might be improved by understanding the care trajectories of people experiencing age-related terminal decline.² She suggests that aged residential care providers are a rich source of data that could be tapped and analysed to inform end-of-life care.

An important study has looked nationally at which general practices are no longer enrolling patients (have closed books).³ Practices close their books when they reach capacity, and this can have serious impact on unenrolled patients who need primary care consultations. A third of all practices were found to have closed books in June 2022, with the issue particularly concentrated around the middle-lower North Island (Wairarapa, Midcentral and Taranaki). General practices with fees towards the middle of the range were more likely to have closed books, whereas Very Low Cost Access were more likely to remain open. As more of our workforce retire, this problem is unlikely to resolve in the short-term.

Many of the papers in this issue have a focus on sexual or mental health. In 2017 gonorrhoea and syphilis became notifiable diseases in 2017, requiring clinicians to complete an anonymised case report form on diagnosis. Contact tracing of partners is important to reduce spread of these sexually transmitted infections (STIs). However, a review of surveillance data has found that contact tracing was recorded as ‘planned’ or initiated’ for only about 80% of cases, with the actual outcomes unknown.⁴ For 20% of syphilis and 16% of gonorrhoea cases, contract tracing was not possible because the contacts were anonymous.

Another STI is the Human Papillomavirus (HPV), with most of cervical cancer now known to be caused by preceding infections of certain HPV subtypes. Cervical screening is switching from cervical cytology to HPV testing, which can be done with vaginal self-swabs. A study looking at primary care staff experience of the new screening pathway piloted in three NZ regions found positive support for self-swabbing, but provided useful lessons to inform the national roll-out.⁵

There are several studies about the rainbow community. Queer-identifying men report use more tobacco and e-cigarettes than the general population. A qualitative study has found that vaping in this population is used to facilitate social interaction and manage stress, in addition to smoking cessation.⁵ Carroll and colleagues surveyed fifth-year medical students about providing health care to lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA+) patients, and concluded that the curriculum needs to include more opportunities to improve students’ knowledge and confidence in this area.⁶

A student health centre which initiates gender-affirming hormone therapy (GAHT) reviewed the clinical notes of these patients.⁷ Fifty-four had been assigned female at birth, and 31 male at birth, with 94% aged between 18 and 25 years. As the clinic saw only tertiary level students, none were aged under 18. Nearly all (97%) of those assigned female at birth were referred for chest (‘top’) surgery, and 80% of those assigned male at birth for sperm cryopreservation (as GAHT is likely to cause irreversible infertility). The numbers of apteitns initiating GAHT has been escalating, with three times as many in 2022 compared with 2020.

In a viewpoint article, Adams and Neville ask whether Rainbow people (LGBTQIA+) have access to health services that work for them.⁸ While Te Pae Tata promises a ‘new health system’ and improved health outcomes for Rainbow people, the authors caution that more specific and detailed action plans are needed on how equity will be achieved.

People with both mental health and substance use conditions are another very vulnerable population. Of 335 people with these multiple conditions who were surveyed about their primary care experiences, 31% were LGBQA+.⁹ The majority reported positive experiences with these services, although those with four or more diagnoses, or who suffered from bipolar disorder or schizophrenia, were more likely to report discrimination.

Medicinal cannabis is mainly used for chronic pain, as well as for anxiety, depression and insomnia. Cannabinoid products were legalised in Aotearoa New Zealand in April 2020, but many patients report difficulty accessing these medicines, due in part to a reluctance of clinicians to prescribe. Withanarachchie and colleagues interviewed 31 physicians (GPs, secondary care specialists, and cannabis clinicians) who had discussed medicinal cannabis with patients in the previous 6 months.¹⁰ These doctors reported that their biggest barrier to prescribing was lack of clinical evidence supporting cannabis therapy, but the price of the products for patients and concerns about their professional reputation also limited their use. They were more likely to prescribe when all other treatment options had been exhausted.

Clinicians have been issuing ‘green prescriptions’ (written instructions to increase physical activity) since the 1990s. A literature review has found that since 2014, the term is also used for exposures to a wide range of ‘natural spaces’ such as forest bathing, animal-assisted therapy, care farming and ecotherapy.¹¹ The researchers advocate that the term ‘green prescription’ is limited to instructions to increase exercise, and that these other activities are referred to as nature-based interventions to avoid confusion.

Pacific people have high rates of both pre-diabetes and diabetes. Care in the Pacific island nations may not be optimal and there may be lack of data on prevalence to inform services. An audit of the Cook Islands non-communicable disease register and other clinical data held on the Ministry of Health patient information system enabled the demographics of all patients registered with pre-diabetes and diabetes to be quantified.¹² Regular audits will help with monitoring and surveillance of the burden of diabetes. Pacific people with pre-diabetes in NZ appear to be getting positive attention. A survey of primary care clinicians with over half their enrolled patients identified as Pacific pleasingly found that their management of patients with prediabetes included use of health coaches, diabetes nurse specialists and community workers of Pacific descent to educate and discuss management plans.¹³

We finish this issue with a Charms and Harms which looks into benefits and possible adverse effects of pine bark supplement,¹⁴ and a Cochrane Corner on whether obesity is associated with a higher risk of adverse outcomes for COVID-19.¹⁵

Conflicts of interest

Felicity Goodyear-Smith and Tim Stokes are Editors in Chief of the Journal of Primary Health Care.