John Menadue said in the NSW Health Council Report of 2000, “Services should be based where patients and consumers live. The autonomy and dignity of each patient is best serviced by providing services wherever possible outside hospital. So a shift to community multi-disciplinary health teams is a major issue still ahead of us.” He returned to this theme in a recent blog, “A major aim of good health policy for Australia must be to keep people out of expensive hospitals.”
Two South African physicians, Sidney and Emily Kark, working in poor communities started community-based primary health care – community medicine – in 1940. In each community their approach started with community diagnosis, working out the health needs in the community.
In 1973 the Whitlam Government set up the Community Health Program for Australia. It was led by an ex-South African, Dr Sidney Sax, who knew the Kark’s approach very well. His committee recommended that the community health program should be based on primary health care. (1)
One aim was to influence the doctors of the future and so, for the first time, chairs of community practice were funded by the Government in all medical schools. At the time, medical schools were narrowly focused on biomedicine and disciplines concerned with the body’s organ systems. Every medical student could tell you about Virchow’s contribution to pathology in the 19th century, but few knew anything about his statement about the social causes of disease, “Medicine is a social science, and politics nothing but medicine on a grand scale.” (2)
Outside the medical school, the general public were becoming more interested in the way doctors were trained. They were concerned about the neglect of disability, chronic diseases, mental health, addiction, Aboriginal health and other troubling health problems. And preventive medicine was missing from the GP’s repertoire.
I came to community medicine at the UNSW after working in Whyalla, South Australia and Sheffield, England. Sheffield was once the “blackest city” in Europe. Coal dust, smog, untreated childhood infections and tobacco smoking caused the lung diseases I treated at the city’s only respiratory clinic. And the impoverished and dank suburbs where I worked as a GP showed me how the social world played out in people’s health. This convinced me of the importance of social medicine.
These problems of health in the community were seen as lost causes in the medical schools of the day but over time, and to a varying extent, they have been picked up in contemporary undergraduate teaching.
Public health was a Cinderella discipline. It was regarded by most medical students as boring stuff about drains, sewerage, unimaginative health promotion interspersed with dry statistics. But with the capacity to collect large datasets and the increasing power of commuters to analyse and interrogate data there was an explosion in enthusiasm for public health. Important questions could now be answered and integrated into the guidelines for medical practice. Epidemiology now makes enormous contributions to the thinking and practice of day-to-day medicine.
But these technical developments – seeing the world through a computer screen – marginalised the messy business of dealing with the day-to-day lives of troubled people, working alongside others to deal at the grass roots with their predicaments.
In the recommendations of the Community Health Program for Australia was the central role of the GP in multidisciplinary community health teams. And progressively, but slowly, medical schools have come to accept general practice as a legitimate academic discipline and area for postgraduate training and specialisation.
In parallel with the academy, the Commonwealth aimed to support general practice through creating networks of GPs. These were known as Divisions of General Practice during the Howard government. They were renamed Medicare Locals in the health reforms of the Rudd government, giving them increased responsibilities and funding.
The current government is funding Primary Health Networks across Australia.
“Primary Health Networks (PHNs) have been established with the key objectives of increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes, and improving coordination of care to ensure patients receive the right care in the right place at the right time.” (3)
PHNs will have increased responsibilities for the populations in their geographical footprints. For example, in meeting local and regional needs for mental health and drug and alcohol problems, and managing the burgeoning problems of chronic disease as well as preventing and treating the common illnesses and injuries seen by GPs.
Community medicine is not dead, it is there in the principles which will inform the new PHNs with their defined responsibilities for communities and “community diagnosis” in their localities.
- A Community Health Program for Australia, Report from the National hospitals and Health Services Commission: Interim Committee, June 1973. Australian government publishing service, 1973
- Anderson MR, Smith L and Sidel V W What is Social Medicine? Monthly Review, vol. 56, No. 8, January 2005. The authors said, “Rudolf Virchow is considered by many to be the founder of social medicine.”
Ian Webster is Emeritus professor of Public Health and Community Medicine, University of New South Wales.