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Van Weel and Kidd cite that primary health care addresses the health needs of all patients at the community level, integrating care, prevention, promotion and education. Primary health care improves the performance of health systems by lowering overall health care expenditure while improving population health and access. The aims of primary health care overlap with those of universal health coverage, which aims to ensure access to essential health services and safe, effective and affordable essential medicines and vaccines for all people. To achieve universal health coverage, reforms should focus on strengthening primary health care to ensure equity and cost containment. Health system reforms should be monitored with indicators that reflect the core characteristics of primary health care: continuity of care, person- and population-centeredness, coordination of care, prevention, health promotion and patient autonomy.

The Alma Ata declaration’s compelling vision of health for all will not be realised until we take community level prevention seriously, argue Luke Allen and colleagues

Non-steroidal anti-inflammatory drugs and colchicine used to treat gout arthritis have gastrointestinal, renal, and cardiovascular adverse effects. Systemic corticosteroids might be a beneficial alternative. We investigated equivalence of naproxen and prednisolone in primary care. We did a randomised clinical trial to test equivalence of prednisolone and naproxen for the treatment of monoarticular gout. Primary-care patients with gout confirmed by presence of monosodium urate crystals were eligible. 120 patients were randomly assigned with computer-generated randomisation to receive either prednisolone (35 mg once a day; n=60) or naproxen (500 mg twice a day; n=60), for 5 days. Treatment was masked for both patients and physicians. The primary outcome was pain measured on a 100 mm visual analogue scale and the a priori margin for equivalence set at 10%. Analyses were done per protocol and by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN14648181. Data were incomplete for one patient in each treatment group, so per-protocol analyses included 59 patients in each group. After 90 h the reduction in the pain score was 44·7 mm and 46·0 mm for prednisolone and naproxen, respectively (difference 1·3 mm; 95% CI −9·8 to 7·1), suggesting equivalence. The difference in the size of change in pain was 1·57 mm (95% CI −8·65 to 11·78). Adverse effects were similar between groups, minor, and resolved by 3 week follow-up. Oral prednisolone and naproxen are equally effective in the initial treatment of gout arthritis over 4 days. Rheumatology Research Fund Arnhem, Netherlands.

Background: Long-term antidepressant use has increased exponentially, though this is not always according to guidelines. Our previous randomized controlled trial (RCT) showed that participants using antidepressants long term without a proper indication were apprehensive to stop: only half were willing to attempt to discontinue their antidepressant use. The objective of this study was to explore participants’ barriers and facilitators for stopping long-term antidepressant use without a current proper indication. Methods: Semistructured interviews with participants from the intervention group of our RCT, a cluster-RCT in general practice in the Netherlands. The latter study was a stop trial with patients on long-term antidepressant use without a current indication (no psychiatric diagnosis). Participants of the intervention group of the RCT had been provided with advice to stop antidepressants. Participants of the current interview study were purposively sampled (from the intervention group of the RCT) to ensure diversity in age, sex, and intention to discontinue the antidepressant. Analysis was performed as an iterative process, based on the constant comparative method. Data collection proceeded until saturation was reached. Results: A total of 16 participants were interviewed. Fear (of recurrence, relapse, or to disturb the equilibrium) was the most important barrier; prior attempts fueled these anticipations. Also prominent as a barrier was the notion that antidepressants are necessary to counter a deficiency of serotonin. Facilitators were information on duration of usage given at the time of first prescription and confidence in a successful attempt. We found many participants struggling between barriers and facilitators to discontinue and participants not discontinuing while experiencing no barriers (ambivalence). Conclusion: Fear is an important motive for patients considering discontinuation of antidepressants. Serotonin deficiency as explanation for antidepressant effectiveness promotes life-long use and hinders discontinuation of antidepressant treatment. The prospect of discontinuation at first prescription can facilitate a future discontinuation attempt. General practitioners should be aware of their patients’ fears, expectations, and attributions toward antidepressant use/discontinuation, and of new developments in taper methods.

The WHO definition of health as complete wellbeing is no longer fit for purpose given the rise of chronic disease. Machteld Huber and colleagues propose changing the emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges

Background A growing number of prognostic indices for chronic obstructive pulmonary disease (COPD) is developed for clinical use. Our aim is to identify, summarize and compare all published prognostic COPD indices, and to discuss their performance, usefulness and implementation in daily practice. Methods We performed a systematic literature search in both Pubmed and Embase up to September 2010. Selection criteria included primary publications of indices developed for stable COPD patients, that predict future outcome by a multidimensional scoring system, developed for and validated with COPD patients only. Two reviewers independently assessed the index quality using a structured screening form for systematically scoring prognostic studies. Results Of 7,028 articles screened, 13 studies comprising 15 indices were included. Only 1 index had been explored for its application in daily practice. We observed 21 different predictors and 7 prognostic outcomes, the latter reflecting mortality, hospitalization and exacerbation. Consistent strong predictors were FEV 1 percentage predicted, age and dyspnoea. The quality of the studies underlying the indices varied between fairly poor and good. Statistical methods to assess the predictive abilities of the indices were heterogenic. They generally revealed moderate to good discrimination, when measured. Limitations: We focused on prognostic indices for stable disease only and, inevitably, quality judgment was prone to subjectivity. Conclusions We identified 15 prognostic COPD indices. Although the prognostic performance of some of the indices has been validated, they all lack sufficient evidence for implementation. Whether or not the use of prognostic indices improves COPD disease management or patients' health is currently unknown; impact studies are required to establish this.

The COVID-19 pandemic has modified organisation and processes of primary care. In this paper, we aim to summarise experiences of international primary care systems. We explored personal accounts and findings in reporting on the early experiences from primary care during the pandemic, through the online Global Forum on Universal Health Coverage and Primary Health Care. During the early stage of the pandemic, primary care continued as the first point of contact to the health system but was poorly informed by policy makers on how to fulfil its role and ill equipped to provide care while protecting staff and patients against further spread of the infection. In many countries, the creativity and initiatives of local health professionals led to the introduction or extension of the use of telephone, e-mail and virtual consulting, and introduced triaging to separate 'suspected' COVID-19 from non-COVID-19 care. There were substantial concerns of collateral damage to the health of the population due to abandoned or postponed routine care. The pandemic presents important lessons to strengthen health systems through better connection between public health, primary care, and secondary care to cope better with future waves of this and other pandemics.

Chris van Weel and Ryuki Kassai look at efforts to strengthen primary care and call for regional and international collaboration to help implement policy

The Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research—a core element of high-quality PHC—in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the micro (practice), meso (institutional) and macro (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and ‘brain drain’ may reduce available research support; however, we provide recommendations on how to deal with these tensions.

Background Patient safety can be at stake in both hospital and general practice settings. While severe patient safety incidents have been described, quantitative studies in large samples of patients in general practice are rare. This study aimed to assess patient safety in general practice, and to show areas where potential improvements could be implemented. Methods We conducted a retrospective review of patient records in Dutch general practice. A random sample of 1,000 patients from 20 general practices was obtained. The number of patient safety incidents that occurred in a one-year period, their perceived underlying causes, and impact on patients' health were recorded. Results We identified 211 patient safety incidents across a period of one year (95% CI: 185 until 241). A variety of types of incidents, perceived causes and consequences were found. A total of 58 patient safety incidents affected patients; seven were associated with hospital admission; none resulted in permanent disability or death. Conclusions Although this large audit of medical records in general practices identified many patient safety incidents, only a few had a major impact on patients' health. Improving patient safety in this low-risk environment poses specific challenges, given the high numbers of patients and contacts in general practice.