Should clinicians be responsible for the population as well as individuals?

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Historically, clinicians have had a strong tradition of connecting the health of the individual in their surgery to the population's health. Doctors were, for example, active in early campaigns for clear air and clean water.

More recently, many doctors have called for a ban on smoking in public places and a reduction of salt in food, and some choose to train specifically to become public health specialists. But what about the 'jobbing' clinician? Do they have a responsibility for the population as well as the individual?

At the BMJ and The King's Fund topical debate at our Annual Conference last week I argued that they do.

Many of the causes of ill health that clinicians see and treat are more than simply physiological: our circumstances shape our health. Our immediate environment; our family relationships and social networks; the community in which we live, including the availability of transport and green spaces; as well as factors of the wider society, including health inequalities, levels of unemployment and poverty, all influence our health. Clinicians have a duty to improve health as well as treat disease – they need to take a holistic approach to wellbeing.

GPs have a particular responsibility for a population through their registered list and the traditional geographical focus of that list. This will become more important as they take on commissioning responsibilities. In future they will not only be providers of primary medical services but responsible for using public money wisely to meet the needs of their population. How well placed are GPs to consider this wider population?

Our forthcoming research on the impact of the Quality and Outcomes Framework (QOF) on public health and health inequalities identified a number of barriers.

Even in deprived practices and spearhead areas, where inequalities are a priority for the primary care trust, the majority of GPs did not believe they have a role in public health and reducing health inequalities. This mindset will need to change if consortia are to actively engage with local authorities, who it is proposed in the recent White Paper will take over responsibility for improving health.

Most practices were not using data to proactively case find or reach out to 'at risk' patients – instead data systems were designed to maximise QOF points, and the funding associated with those points. Data systems and incentives need to encourage practices to identify unmet demand, reach out to patients and close gaps in care.

To date QOF has provided incentives for secondary prevention, and practices have responded by putting in place more systematic approaches to chronic disease management. There are currently few incentives for GPs to offer primary prevention, and as a consequence these activities are undervalued and, in many cases, not undertaken.

If GPs are to consider the needs of the wider population, they will need different incentives that reward prevention, data on needs as well as on use of health care, and time to step back from the individual patient in front of them. Those leading consortia will need to embrace this wider role and to support practices, particularly those in deprived areas, to deliver better health for all.

This blog also appeared on the British Medical Journal website.


Dr JK Anand

Retired doctor,
Comment date
09 December 2010
I have worked in the NHS. About time the three previous branches were brought back to life - the MOH responsible for his DEFINED POPULATION's health, the GP (in contract to his Executive Council for the health of the INDIVIDUAL PATIENT registered with him and the hospital doctor responsible
for the INDIVIDUAL PATIENT referred to him. The successive governments have messed around with the services and I for one, as a patient, have seen no good results from it all. Give us patients a break. Refrain from more changes.

Steve Cribb

GP Practice Manager,
Comment date
08 December 2010
The government seem hell bent on "scrapping" targets yet do not explain how they will focus attention on ensuring outcomes are achieved. Patients could benefit (as could the NHS purse) from earlier or prevantative interventions but how can GP's take responsibility for an unknown group of patients. Surely, the registration system is the best way to allocate reponsibility and to ensure a joined up approach and continuity of care is given whether it be primary prevention or secondary care?

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