Developing General Practice: The Role of the APO method

Abstract: Abstract General practice is a broad and multifaceted field of knowledge. Political steering instruments declare that general practice and primary care are characterized by a holistic perspective on the individual, with quality, accessibility, continuity, and cooperation being important factors. For the last few decades, quality assurance has been in focus in Swedish health care. Inspiration has come from other countries and from other spheres, such as the manufacturing industry. The dissertation is a case study of the APO method, which is a way of working with the general practitioner’s continuous learning and quality assurance. The aim was to explore the role of the method in general practitioners’ professional development and quality development. Subsidiary aims were: to examine perceptions of a holistic view; to obtain a deeper understanding of the meaning of general practitioners’ work with quality; to investigate how the actual registration phase in an APO audit affects general practitioners; and to develop the APO instrument to measure softer data. We found that a holistic view pervades the clinical work of general practitioners. A holistic view means being able to offer biomedical and psychosocial knowledge and draw on the patient’s experiences. The field of knowledge is under constant development and its practitioners must also develop. General practitioners have an understanding of society’s demand for good and safe health care for everyone, but they make a clear distinction between demands coming from outside (top-down), and obli¬gations from within the profession (bottom-up). Top-down demands are felt to encroach on professional autonomy, and the methods offered are rarely adapted to primary care. Instead the doctors follow up their work with methods developed by the profession. Such methods include documenting one’s own actions, with elements of collegial discussions, such as the APO method, which was devised to measure quantifiable data supplemented with qualitative attributes. The APO method functions in this way when it comes to hard data. We compared audit participants with non-participants in an audit about drug prescriptions. The participants prescribed antibiotics to a lesser extent than the non-participants right from the start. Both groups reduced their prescribing in the initial phases of the audit process. In the pilot audit about a holistic view and knowledge, we studied the possibility of using the audit method for soft variables as well. The audit protocol was supplemented with VAS scales to give greater depth. The results show that the variables and scales worked. This dissertation shows that the APO method can have a role to play in the development of the field of general practice, both in clearly biomedical spheres and in more general aspects of the work. It is problematic to achieve systematism in work with quality since there is such a strong opposition between the need for professional autonomy and the methods offered. The APO method satisfies the profession’s need for self-determination and reflection, above all through collegial comparison and discussion.