Research
Shabir Moosa, Raymond Downing, Bob Mash, Steve Reid, Stephen Pentz and Akye Essuman
Understanding of family medicine in Africa:
a qualitative study of leaders’ views
INTRODUCTION of general practice in the UK in 2007, as 
Abstract The World Health Organization argued that well as operational definitions of attributes 
Background primary care service delivery needs reform,
1 of primary health care in Canada.5–8 African 
The World Health Organization encourages principally shifting towards comprehensive primary care systems are poorly resourced 
comprehensive primary care within an ongoing primary care within ongoing relationships and hence rely considerably on the primary 
personalised relationship, including family 
physicians in the primary healthcare team, but between patients and providers, whether healthcare team, usually led by non-
family medicine is new in Africa, with doctors providing care as individuals or as teams. doctors. Generalist doctors are expected to 
mostly being hospital based. African family The primary care team is also expected staff district hospitals, to bring hospital care 
physicians are trying to define family medicine to take responsibility for the health of a closer to the community.
in Africa, however, there is little clarity on the 
views of African country leadership and their defined population and not just the patients Most generalist doctors, including private 
understanding of family medicine and its place presenting at facilities. GPs in the small private sector, function 
in Africa. Internationally, family medicine promotes with only their undergraduate training. 
Aim this person-centred and community- Postgraduate training in family medicine 
To understand leaders’ views on family medicine orientated approach; however, much of the has only emerged in six countries (Kenya, 
in Africa. international primary care system is based Ghana, Nigeria, South Africa, Tanzania, and 
Design and setting on doctors delivering first-contact care. Uganda) over the past 20 years. This has only 
Qualitative study with in-depth interviews in nine There is a worldwide trend to team-based become substantial recently; for example, 
sub-Saharan African countries. care (including nurses, family physicians the specialty has only been fully recognised 
Method and community health workers), owing to in South Africa since 2007. This success 
Key academic and government leaders were spiralling health costs. This is supported by has emerged mostly from responding to 
purposively selected. In-depth interviews the World Health Assembly.2 public service needs, especially in district 
were conducted using an interview guide, and 
thematically analysed. While strong primary health care is hospitals. Family physicians have felt 
essential to provide efficient and effective the need for surgical, anaesthetic, and 
Results health care in both resource-rich and procedural skills to provide services at 
Twenty-seven interviews were conducted with 3
government and academic leaders. Responders resource-poor countries,  the role of the district hospital, as well as skills in 
saw considerable benefits but also had concerns family medicine cannot be assumed to be mentoring and teaching frontline primary 
regarding family medicine in Africa. The benefits the same everywhere. There have been care workers.9,10 These skills are reflected 
mentioned were: having a clinically skilled renewed efforts globally to define the in training that is different from European 
all-rounder at the district hospital; mentoring 4 11
team-based care in the community; a strong principles and practice of family medicine,  or North American models.
role in leadership and even management in for example, the European definition of African family physicians have felt the 
the district healthcare system; and developing general practice in 2002, the future of family need to clearly define family medicine in 
a holistic practice of medicine. The concerns 
were that family medicine is: unknown or medicine in the US in 2004, and the future Africa, in the light of global trends in family 
poorly understood by broader leadership; poorly 
recognised by officials; and struggling with 
policy ambivalence, requiring policy advocacy 
championed by family medicine itself. S Moosa, MBChB, MFamMed, MBA, family Cape Town, Cape Town, South Africa.
physician; S Pentz, MSocSci, researcher, 
Conclusion Address for correspondenceDepartment of Family Medicine, University of 
The strong district-level clinical and leadership Shabir Moosa, Department of Family Medicine, 
expectations of family physicians are consistent Witwatersrand, Johannesburg, South Africa.  Faculty of Health Sciences, University of 
with African research and consensus. However, R Downing, MD, DTM&H, lecturer, Department Witwatersrand, Johannesburg, 2193, South Africa. 
leaders’ understanding of family medicine is of Family Medicine, Moi University School of E-mail: shabir@drmoosa.co.za
couched in terms of specialties and hospital care. Medicine, Eldoret, Kenya. A Essuman, BSc, Submitted: 30 July 2012; Editor’s response: 
African family physicians should be concerned MBChB, FGCP, lecturer, University of Ghana, 28 August 2012; final acceptance: 5 September 
by high expectations without adequate human Accra, Ghana. B Mash, PhD, MRCGP, FCFP(SA), 2012
resource and implementation policies. head of Division, Family Medicine and Primary This is the full-length article (published online  
Care, Stellenbosch University, Matieland, South 
Keywords 25 Feb 2013) of an abridged version published Africa. S Reid, BSc Med, MBChB, MFamMed, 
Africa; definition; family practice; healthcare in print. Cite this article as: Br J Gen Pract 2013;  
systems. PhD, chair of Primary Health Care, University of DOI: 10.3399/bjgp13X664261
e209  British Journal of General Practice, March 2013
PRIMAFAMED Africa Network, who 
How this fits in were all briefed and trained in qualitative interviewing and orientated towards the 
African leaders are positive about the study objectives, performed the interviews. 
contribution that family medicine can Written informed consent was obtained 
make to health systems in Africa, but are before a 30–60 minute interview. A standard 
unclear as to exactly what the role of the 
family physician is, or should be. There are operating procedure and interview guide 
high expectations of the discipline, some were used to explore the viewpoint of 
of which are unrealistic in the absence of interviewees. Questions asked were:
comprehensive plans. Family medicine 
in Africa needs to advocate for context- 1. Can you tell us about family medicine?
appropriate human resource policies and 2. What are your thoughts on the role of 
implementation plans that appropriately 
include family physicians in the primary family medicine in your country?
healthcare team. 3. What do you think are the issues in 
implementing the discipline of family 
medicine?
medicine and experiences in Africa. One 4. What are critical human resource issues 
study has defined the principles of family to establishing family medicine?
medicine in Africa from the perspective 5. Do you have anything else to add?
of family physicians.9 A second study 
explored grassroots views on the role of 
the generalist doctor in Africa.10 The 2nd Interviews were recorded digitally 
African Regional World Organisation of and conducted in English, except in the 
Family Doctors (WONCA) Conference also Democratic Republic of the Congo (DRC) 
reached a consensus statement in 2009 where they were conducted in French and 
that articulates what family medicine has to translated into English by the interviewer. 
offer in an African context.12 This academic The interviewers transcribed digital 
discourse and growing consensus is being recordings verbatim. The transcriptions 
used to engage various leaders in sub- were separately validated against digital 
Saharan Africa on implementation of family recordings.
medicine. The aim of this study was to 
understand the views of key leaders in Data analysis
sub-Saharan Africa, in order to engage Qualitative data analysis followed 
13
effectively. Key areas explored were the framework method.  All authors 
how leaders understood the discipline familiarised themselves with the data. 
of family medicine, and their views on The six authors met in November 2011, 
implementation challenges and human identified major and minor themes from 
resource issues. the initial 12 transcripts, and developed a 
thematic index. The text from all transcripts 
METHOD was then systematically coded according 
Study design to the thematic index by one author, using 
This was a qualitative study, using in-depth NVivo 9, and supervised by another author. 
interviews of leaders across the setting These index-coded themes and transcripts 
of nine countries in southern, eastern, were then presented to the research team. 
and western Africa. Members of the The six authors met in February 2012 to 
study population were leaders in higher interpret these and develop key findings.
education institutions or the department 
of health in various countries. Partners RESULTS
in the PRIMAFAMED Africa Network of A total of 27 interviews were conducted 
departments of family medicine in 16 in nine countries (Table 1). These were 
African countries were asked to purposively conducted from June to December 2011, 
identify four key leaders in each country, when it was decided that there were 
who were seen by them as influential to sufficient data for analysis. Attempts to 
the development of family medicine, two interview the other identified leaders had 
in a government department of health and not been successful. The responders were 
two in an academic institution. Those with mostly at the level of head of department, 
postgraduate education in family medicine director, and deputy director in ministries 
were excluded. of health, and vice-chancellor, dean, vice-
dean, and principals in medical schools, 
Data collection and college presidents. Any further detail 
The authors, and key people in the would identify them.
British Journal of General Practice, March 2013  e210
‘A family medicine practitioner is able to 
Table 1. List of responders per country and sector do many of the things that it would take 
three or four different specialists to do.’ 
 Number from Number from  (Nigeria G1)
Country government academic institutions
Botswana 1 0 ‘… [family physicians will have] the 
Democratic Republic of the Congo 3 1 competences to practise across a broad 
Ghana 2 2 range of specialties in a non-specialist 
way.’ (Nigeria G1)
Kenya 2 2
Malawi 1 2 Because of this broad clinical expertise, 
Nigeria 1 0 many responders commented positively 
Rwanda 2 2 that family medicine would reduce referrals 
South Africa 3 1 to central hospitals:
Uganda 1 1
‘I think family medicine, for me, it’s like a 
Total 16 11 link between health systems, because we 
have the referral hospitals, we have district 
hospitals, and we have health centres and 
Responders described numerous we have communities.’ (Rwanda A1)
potential benefits, as well as concerns, 
regarding family medicine (Box 1). ‘Family medicine could reduce noticeably 
There were no clear differences between referrals to hospitals.’ (Kenya A1)
academic and government leaders’ views. 
In the quotations, responders are labelled ‘We are looking at improved skills available 
by country, as either government (G) or closer to the people and this will lead 
academic (A), and interview number. to reduced referrals to central hospitals, 
which are already overstretched in terms 
Benefits of human resources.’ (Malawi G3)
Benefits were linked to the wide range 
of roles that stakeholders saw for family This impact on referrals was also 
medicine, especially in filling gaps in their because of the expected rural location of 
health systems: family physicians:
‘I am looking at the gaps that exist in ‘It could help in rural area where we could 
our healthcare delivery system. The family not find all specialties, it could reduce 
physician must fill those deficiencies …’ number of transfer from rural hospital to 
(Malawi G3) town hospital.’ (DRC A4)
A clinically skilled all-rounder based at the Mentoring team-based care in the 
district hospital. Family physicians were community. There was a strong sense 
viewed as ‘all-round specialists’, who could that family physicians should be involved 
care for the most common presentations, with supervision and mentoring of medical 
conditions, and emergencies at district officers, nurses, clinical officers, and allied 
hospitals. This was often conceptualised as healthcare workers. Family physicians 
an integration of four traditional hospital- were expected to lead clinical governance, 
based disciplines; medicine, surgery, outreach support, and task shifting with 
obstetrics, and paediatrics. The scope was these cadres in district facilities, linking 
considered wider and higher than for the them to the specialists. The capacity for 
usual doctor: research, critical thinking, and evidence-
based medicine was seen as crucial to 
maintaining and developing the quality of 
the team:
Box 1. Key themes identified
Benefits Concerns ‘The family physician would be the … main 
• A clinically skilled all-rounder based at the • Family medicine is unknown or poorly understood person at the district hospital … who can 
   district hospital • Poor recognition, visibility, and role clarity supervise the medical officers there.’ 
• Mentoring team-based care in the community • Struggling with policy ambivalence and needs (Rwanda A3)
• A strong leadership role in the district    advocacy 
   health system  ‘[The family physician would be] a mentor 
• Developing holistic practice of medicine and supporter of people around clinical 
governance in primary health care at the 
e211  British Journal of General Practice, March 2013
district and sub-district level.’ (South Africa they are the ones who should be involved 
G2) in strategic planning development and 
managing of primary healthcare services, 
Family physicians were seen as key to and beyond this they should be the ones 
training the full team: who are doing some kind of monitoring 
‘They can be the resource providers in or evaluating the quality of healthcare 
terms of training for the other cadres.’ services.’ (Kenya A2)
(Malawi A1) ‘It would be desirable that these team 
leaders should also be trained in this area to 
‘They are also expected to train the middle encompass people management, resource 
level and lower cadres to build effective management, as well as to be able to 
teams for the improvement of primary critically analyse the delivery of health care 
healthcare services.’ (Malawi G3) in the district as a whole.’ (Malawi G3)
The family physician was seen as Developing holistic practice of medicine. 
working deep in the community, in charge It was felt that family medicine in Africa 
of a health centre, and consequently the should be holistic. Family physicians are 
community around it. They were expected expected to see the patient as a whole, 
to undertake community diagnoses, take thinking broadly and not in specialties. 
charge of priority health programmes, and Providing care was seen not only as giving 
strive for improvement in population-based drugs, but also as exploring psychosocial 
health: issues in a family and community context:
‘He will look at the causes of these problems ‘Family medicine is a holistic medicine, 
and the community impact and try [to] also which treat [s] patient [s] but not disease.’ 
go beyond and try to resolve those causes.’ (DRC A1)
(Rwanda A1)
‘The challenge was … specialties, they 
‘They’ve done well and transcend the go away with this knowledge in boxes … 
health centre [going] to CHPS [the smaller we should produce a person who thinks 
clinics].’ (Ghana G4) holistically.’ (Kenya A1)
A strong leadership role in the district Prevention, health promotion, and 
health system. Many responders saw public health considerations were seen as 
family physicians providing strong important:
leadership and even management of the 
district healthcare system. They were seen ‘[A family physician should be] a kind of 
as crucial to the organisation of the primary generalist who can really take care of the 
healthcare system, including community whole family, but not only the curative part 
health workers, owing to their experience but also preventive.’ (Rwanda A1)
as clinicians. The proposed role for family 
physicians varied, from being the ‘chief’ of A few stakeholders considered continuity 
the health district, to being a ‘consultant to as important:
district medical practice’:
‘[It is important] that patients and the doctor 
‘Family physicians could help to organise are all the time linked … to meet the 
[the] primary health care system.’ (DRC A4) expectations of the family … as Malawi is 
developing.’ (Malawi A2)
‘These people are team leaders for the 
district as a whole.’ (Malawi G3) Concerns
Family medicine is unknown or poorly 
‘I think that having a specialist who should understood. A strong theme was that the 
be a leader of quality around the whole broader community of policymakers have 
gamut of primary health care is a good not yet conceptualised the contribution that 
thing.’ (South Africa G2) family medicine can make to their health 
systems. Many responders felt that family 
They were also expected to be involved in medicine was an unknown discipline with 
the district management team. It was felt no clear explanations about what it has to 
that they needed management skills: offer in Africa:
‘These are the kind of doctors that should ‘It will not be easy to implement it since 
take charge of the programmes and again people don’t know it.’ (Rwanda G2)
British Journal of General Practice, March 2013  e212
‘There is no clear explanation about family not designed to show off their training to 
medicine.’ (DRC G3) best ... You know, they get put into jobs like 
CEOs [chief executive officers] of hospitals 
‘So you are kind of the super GPs.’ (South or things like that.’ (South Africa G2)
Africa G3)
In some settings, misunderstandings The creation of a new specialty inevitably 
about the training of family physicians creates tension with existing cadres, 
also hindered policy commitment. One especially when their respective roles 
responder reported the confusion of a potentially overlap. The confusion between 
minister of health: family medicine and public health medicine 
was mentioned several times. There was 
‘Now you’re going to train this person who also confusion between family medicine and 
is 10 specialties. I will need 20 years to train internal medicine. The supervision of mid-
them.’ (Kenya A1) level healthcare workers such as clinical 
officers may also need to be renegotiated if 
Poor recognition, visibility, and role clarity. family physicians are available.
Responders stated that the recognition South African responders commented 
of family medicine was another issue of that, with the growing role of family 
concern. They felt that family medicine is physicians, their clinical governance role 
seen as inferior to other disciplines and appeared similar to that of chief medical 
not accepted by other specialists as a fully- officers, who have been in the system for a 
fledged specialist programme. Responders while. This was seen as a source of conflict:
were also concerned about the integration of 
family medicine into the academic system: ‘The threats are recognition by your peers 
… mutual respect … and support from other 
‘The fact that the discipline is relatively disciplines.’ (Ghana A2)
new practice, it means that it is not fully 
institutionalised … not fully mainstreamed ‘It might well be a recipe for some 
… not fully acceptable by the existing contestation and fought with difficulty until 
practices.’ (Kenya G4) the rules of the game become clearer.’ 
(South Africa G2)
‘Up till recently, the specialisation was not 
valued as it should have been. General There was acceptance that administrative 
practice is not regarded as a specialisation.’ responsibilities came with seniority and a 
(Nigeria G1) leadership role in the district, but there was 
caution, especially in South Africa, that the 
South African responders felt that role of the family physician should remain 
family physicians could be challenged primarily clinical:
by high expectations, as clinically skilled 
all-rounders at the district hospital. They ‘[They should] stay with the clinical role.’ 
recommended strong training of family (South Africa G3)
physicians, with awareness of their 
limitations and possible sub-specialties in Struggling with policy ambivalence and 
family medicine, such as palliative care. needs advocacy. A concern was raised that 
The case for family medicine is also family medicine is not clearly defined from 
weakened by the lack of African evidence an African perspective, and that funders 
for its contribution where it has been and international bodies, as well as faith-
implemented. The small numbers of based organisations in some countries, 
family physicians also make it difficult to inappropriately shift the development of 
demonstrate an impact. In some instances, family medicine to serve their own agendas. 
the few family physicians that are in the The lack of local trainers also leads to the 
system have been inappropriately placed, use of foreign-trained family physicians, 
some becoming administrators in large with the potential for inappropriate models 
hospitals: and poor sustainability.
A lack of recognition with medical 
‘They are not playing as visible and councils, a lack of local professors, the 
important a role as they should be and low priority given to family medicine 
they are not, obviously they are not, in such training, and a lack of budget, hinder policy 
numbers that they can make an impact on commitment to family medicine:
society.’ (Nigeria G1)
‘Family medicine is not yet seen as a priority 
‘They have been shunted into jobs that are area of investment.’ (Rwanda A3)
e213  British Journal of General Practice, March 2013
‘Family medicine does not have support family physician. The principal clinical role 
from DRC political and academic leaders.’ was balanced by a number of non-clinical 
(DRC A1) roles such as supervision, mentoring, 
leadership, and improvement of the quality 
There appears to be policy ambivalence in of care and health systems; all these roles 
some countries. Although family physicians were held to be important. The responders 
are being trained and appointed into posts, also expect family medicine to improve 
national strategic human resource planning the supervision and mentoring of mid-
has yet to mention family physicians clearly level staff, enhance teamwork, enhance 
within them: a holistic approach to patient care, and 
improve the quality of primary care. Each 
‘Although the ministry has not finalised its of these roles is consistent with African 
human resource strategic document for the family physicians’ views as expressed in 
next 5 years, the need for family physicians the consensus statement,12 but different 
is clear in the documentation.’ (Ghana A1) from family medicine in other parts of the 
world. The large extent of hospital-based 
‘We’ve been talking a lot about family practice versus office- or clinic-based 
medicine and the implementation of all practice appears to be one distinct feature 
these issues, but we haven’t had a detailed of family medicine in Africa. African family 
human resource plan to support this.’ physicians see hospital care as an essential 
(South Africa A1) part of comprehensive primary health care, 
and their current role as a phase in the 
Responders felt that strong advocacy development of comprehensive primary 
was required by family medicine itself, with health care in Africa.
stronger associations, the development of However, the conceptualisation of family 
academic departments, and engagement medicine is underdeveloped in Africa, with 
with leaders: a wide variety of understandings as well as 
a general lack of clarity. The discourse on 
‘I think that you have a lot of advocacy to do family medicine by these leaders appears 
… make the move and we will support you.’ to be couched in specialist- and hospital-
(Ghana A1) centric terms. It is defined in terms of 
how it combines aspects of established 
The following statement sums up this specialties and helps to reduce the 
sentiment: workload of specialists at central hospitals. 
Many responders saw family medicine as 
‘A lot of people are not knowing what role merely a combination of four major clinical 
they may play and if we are not careful specialties, or even as a stepping stone to 
the policy makers may not be able to later specialisation, rather than a positive 
provide the required resources to support career option in its own right. While some 
the implementation of this programme. leaders saw family medicine as an extension 
The shortage of people in this particular of the GP role as practised in high-income 
area may not be able to show the kind of countries, most saw the family physician in 
impact that the programme is having. We Africa as largely a hospital specialist. The 
need to create awareness on the need of concept of personal care of individuals and 
this programme and especially with policy their families over time, as with general 
makers and experts.’ (Kenya A2) practice or family medicine as understood 
and practised in high-income countries, 
DISCUSSION was mentioned but seen as a distant goal. 
Summary In addition, the significant role in clinical 
Responders were both positive and governance, management, teaching, and 
encouraging about family medicine making research is not adequately quantified and 
a difference to fragile and uncoordinated appears dependent on local circumstances. 
health services, particularly in under- Responders did urge greater clarity and 
served areas. The primary role of the advocacy from family medicine. There were 
family physician was seen as the ‘all- no clear differences between academic and 
round specialist’ at smaller hospitals, government leaders’ views.
in the absence of other specialists. The 
strongest motivation appeared to be Strengths and limitations
reducing referrals to overburdened central The strengths of this study lie in its broad reach 
hospitals. Some responders identified the across nine countries in southern, eastern 
district hospital and the community health and western Africa, encompassing the views 
centre as the primary sites of practice of the of influential informants who are directly 
British Journal of General Practice, March 2013  e214
concerned with family medicine. Despite as community health workers, clinical 
the limitation of using multiple interviewers, officers, clinical nurse practitioners, 
with the possible lack of adherence to the and managers, as well as an adequate 
interview guide and communication skills, number of family physicians per facility or 
there was sufficient convergence to extract district. Family physicians must also be 
common, relevant themes. It is possible given clear authority to fulfil their expected 
that additional viewpoints and themes might responsibilities and be held accountable. 
have emerged if additional countries or This concern echoes that of Kenyan family 
leaders unsupportive to family medicine physicians, who often felt overwhelmed by 
had been included in the study. The findings their workload.15 While family physicians 
cannot be generalised to Africa as a whole, aspire to a personalised family-based and 
but give a useful insight to the viewpoints of community-oriented primary care (COPC) 
leaders in multiple settings, which should approach in Africa,9,16 there is little evidence 
certainly be considered when discussing of this in action and little explicit policy 
the development of family medicine in an support for the development of family 
African context. medicine in a COPC approach. As noted by 
African family physicians9 and generalist 
Comparison with existing literature clinicians,10 and confirmed by Kenyan family 
In terms of the global typology of primary physicians,15 ‘the closest they got to the 
care organisational development, these community was the door of the outpatient 
Funding leaders’ views of family medicine in Africa unit’. Advocacy is compromised when 
This research was done in the framework appear mired in a grey area between the desired service or role that is being 
of the HURAPRIM Project, which received the hospital (with its divided specialist- promoted is unclear.
funding from the European Union’s Seventh orientated structure and processes, and 
Framework Programme (FP7-AFRICA-2010) focus on individual patient outcomes), Implications for practice and research
under grant agreement no. 265727 as well as and the district health system (with its The parallel processes of policy formation 
healthbridge. generalist, primary care, public health, and and the building of consensus among 
Ethical approval population-orientated approach).
14 policymakers that is based on evidence17 is 
Ethical approval was given by the University of Leaders lack a strong positive crucial to the development of the discipline. 
the Witwatersrand’s Human Research Ethics understanding of the generalist paradigm The ideal balance of clinical, educational, and have a tendency to define family managerial, and community-oriented 
Committee (Medical) (M110105) in May 2011, medicine in terms of deficiencies in the roles of the family physician in the African 
Moi University’s Institutional Research Ethics system: a discipline to ‘fill gaps’ without an context needs further evaluation to make 
Committee (IREC/2011/78), and the Ethical overarching conceptual framework of the the task of family physicians feasible and 
and Protocol Review Committee of the unique and specific contribution of well- effective. In the process, the case for family 
University of Ghana Medical School (MS-Et/ trained generalists. There is also a concern medicine needs to be made in a more 
M.4-P5.5/2011-12). Interviewees were not that the expectations of the family physician unified and consistent manner, as well 
offered any monetary reward for participating to fill all the gaps are unrealistic, if they as advocated more widely, to overcome 
in the study. The data produced in the project are seen as just one ‘super GP’ fulfilling all current misconceptions and lack of 
remain confidential, and the interviewees the expected clinical, surgical, community, awareness. There needs to be a clearer 
remain anonymous in all transcripts and and administrative roles. Fulfilling all these articulation of human resource policies 
analyses. roles will require the presence of other and implementation strategies, by family 
Provenance types of well-trained health workers, such physicians themselves.
Freely submitted; externally peer reviewed. 
Competing interests
The authors have declared no competing 
interests.
Acknowledgements
There were several interviewers and 
facilitators that require acknowledgement 
in this extensive study: Drs O Nkomazana 
(Botswana), O Ayankogbe (Nigeria), L 
Dullie (Malawi) I Besigye (Uganda), M 
Flinkenflogel (Rwanda), A Mugali (Rwanda), T 
Rubanzabigwi (Rwanda), J Thigiti (Kenya), H 
Lawson (Ghana), and M Masoda (DRC).
Discuss this article
Contribute and read comments about 
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e215  British Journal of General Practice, March 2013
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