Primary care: The central function and main focus of the health system

Forty-three years ago, the World Health Organisation’s Alma-Ata Declaration¹ formally adopted the position that ‘It [primary health care] forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community.’¹ This has never been an easy notion for governments to understand. The 20^th century saw a rise in health technology and growth of hospital care as the embodiment of health systems. Primary care is, by comparison, difficult to define (it is not a place, like a hospital), difficult to arrange (there are many different primary care approaches), and difficult to control (because lines of accountability are blurred). Largely left to develop organically, primary health care is different in different places. Despite this, signatory countries to the Alma-Ata Declaration persevered for many years with attempting to develop health systems aligned to inclusiveness, equity and other primary health care principles. Today, in the context of a global pandemic, we see retreat from that position. There is increasing talk of health system ‘failure’ without more critical care beds in hospitals, and COVID-19 vaccinations are seen as a way to protect hospitals from being over-run, rather than primarily as a way of protecting people from harm.

Internationally, a heavy toll on communities has arisen from governments’ concentration of COVID-19 strategies on hospitals at the expense of primary care.² In this issue we publish a letter from authors in Iran, a country with experience of five 21st century pandemics.³ These authors suggest that repeated COVID-19 waves may be attributable to lack of attention on primary care, resulting in challenges to the resilience of health systems. In dealing with global challenges, it is important for every country to learn from others.

There is a great deal of conflicting information about COVID-19 becoming available on the internet and passed around in different social circles. In this confusion of ideas, scepticism is healthy. Information gleaned from news media and other websites may hold some truth, but this cannot be expected or guaranteed. Websites alone should therefore not guide clinical practice. The closest thing to ‘truth’ is reliably found in the scientific literature, because only there can one find reports of searches for ‘truth’ that have been independently reviewed by other scientists and appraised for credibility. Even so, individual research reports should seldom change clinical behaviour or be assumed to offer anything but the best we can determine at this time and in this way. Established nearly 30 years ago, the Cochrane Collaboration combines scientific research in particular topics to derive independent messages about the current state of knowledge in healthcare. Over the last two years the Cochrane Collaboration has been much occupied by COVID-19. Cochrane New Zealand provides this Journal with brief summaries of the latest research coming out of the Cochrane Collaboration globally. In this issue Vanessa Jordan reports on unsuccessful efforts to find a role for antibiotics in the treatment of COVID-19.⁴

In the last issue we published general practitioners’ views of changes in prescribing practices arising from COVID-19 restrictions.⁵ Here, we follow with pharmacists’ perceptions of the same changes, providing further detail about refinements needed to truly embed the advances prompted by the pandemic.⁶ Other articles related to COVID-19 in this issue show how the Japanese public altered their healthcare-seeking behaviours during pandemic waves⁷ and how an interprofessional education programme adapted to remain viable.⁸

Unrelated to COVID-19, other research articles are about midwives’ experiences in providing care for circumcised women⁹ and a paper about healthcare service providers’ concern at the challenges faced by aged Pacific peoples with cognitive impairment and dementia.¹⁰ Elders from Pacific nations are vital in families and communities as holders of key cultural knowledge yet often live in environments that may increase their risk of cognitive impairment.

The Balint Society of Australia and New Zealand runs an essay competition biennially. We are delighted to publish two of the essays submitted to this competition by undergraduate medical students.¹¹ The competition organisers, Associate Professor Hamish Wilson and Alexa Gilbert-Obrart, introduce these essays and comment on the importance of ‘storytelling’ in developing professionalism among medical students.¹¹

A Viewpoint articles provides an overview of the use, mis-use and best management of gabapentinoids¹² and another makes a case for more gender-specific research in diabetes care.¹³ Gabapentinoid use is increasing, often for unapproved indications. Along with this is increasing drug-related harm. This article provides guidance on managing the risks associated with gabapentinoid prescribing and identifies groups of high-risk patients. The other Viewpoint article¹⁴ makes the case that women may use complementary and alternative care services and products more than men and that GPs may not know much about complementary medicines and their interactions with mainstream pharmaceuticals. Martini’s reviews in our Potion or Poison column aims to help improve readers’ knowledge about complementary medicine. In this issue, the pharmacology and appropriate use of hempseed oil is explained.¹⁴

Our case report is about a patient diagnosed with renal cancer as a consequence of being screened for lung cancer.¹⁵ Such ‘incidentalomas’ – unforeseen diagnostic findings unrelated to the initial purpose of an investigation – are generally negatively valued. They can lead to further investigations or interventions that would not otherwise have happened, exposing patients to harm through over-medicalisation. Readers must make their own assessment of the relative value of the outcome in this patient’s case.

2021 has not been an easy year for many people around the world. We hope that readers may be able to take time to relax and enjoy life at this season and set out in 2022 in good heart. We send our best wishes to all our readers.