WONCA INTERNATIONAL CLASSIFICATION COMMITTEE (WICC) 1972 – 2019

by Jean-Karl Soler, Malta

In 1972 the World Organisation of Family Doctors (Wonca, then WONCA) resolved that a working party should be established develop a classification of disease in general practice, clearly related to WHO’s International Classification of Diseases (ICD), for presentation to the next meeting. Dr. Robert Westbury of Canada was appointed Convenor. In his first report to Council, in 1974, Dr. Westbury spoke of the enthusiasm and the zeal of those working on the project. His group were working, at that stage, entirely by correspondence. At the General Assembly meeting following Council, he announced that an International Classification of Health Problems in Primary Care (ICHPPC) had been developed to enable family physicians to classify problems (as opposed to diseases) which they met in their daily work.

The General Assembly in November 1974 decided to establish a further working party to deal with the problems of “Terms and Definitions in General Practice/Family Medicine”. Wisely, in July 1975 Executive requested the existing International Classification Committee to accept this extra task, which it did. By August 1976, Dr Westbury was able to report that by the process of five rounds of correspondence the committee had finalised the ICHPPC which had been distributed in typed format to all Member Organizations in 1975. The committee at this stage included: Dr. Robert Westbury from Canada, Dr. Bent Guttorm Bentsen from Norway, Dr. Donald Crombie from Great Britain, Dr. Boz Fehler from South Africa, Dr. Jack Froom from the USA, Dr. Deryk Gallagher from New Zealand, Dr. Klaus- Deter Haehn from West Germany, Dr. Henk Lamberts from The Netherlands and Dr. Philip Sive from Israel.

At the Council meeting in October 1976, Dr Westbury was able to report that his committee had commenced work on the preparation of a definition for each rubric in ICHPPC. The operational definitions were being developed by Dr. Jack Froom. ICHPPC-2 – the version aligned to ICD 9 – was distributed in typed form to Member Organizations in November 1978. The printed version was published by Oxford University Press towards the end of 1979.

During 1979 the committee was working on a conceptually new classification, namely, a Reasons for Encounter Classification (why a person enters the health care system). WHO expressed considerable interest in this project. This project was led by Dr. Henk Lamberts.

In 1980 work had commenced on ICHPPC-2 Defined supported by a generous grant from the National Library of Medicine. A Glossary for Primary Care was being developed under the leadership of Dr Jack Froom. This was published in 1981 by the “Journal of Family Practice” and distributed by Appleton-Century Crofts.

In 1981 WICC, together with all the committees, was given redefined terms of reference namely:

• To obtain international understanding and agreement on nomenclature, classification and definitions in the field of general practice/family medicine.
• To prepare and disseminate an agreed classification of problems in general practice/family medicine and appropriate revisions of such classification.
• To research, develop and disseminate new information regarding classification and glossaries in the field of general practice/family medicine.

In 1982, Professor Jack Froom, was appointed Chairman of the Committee. In his report to the Executive in1982, he indicated that ICHPPC-2 Defined was complete and ready for publication by Oxford University Press. An advance copy of the newly printed ICHPPC-2 Defined was presented to Council. This edition was similar to ICHPPC-2 but contained inclusion criteria for most of the diagnostic titles in the classification. It also contained the International Glossary of Primary Care. It had been endorsed by WHO and was compatible with the new revision of ICD 9.

In 1986, the International Classification of Family Medicine, ICFM was jointly developed by WHO and the Committee, but WHO declined to endorse it or co-publish it. As an outcome of this it was edited by Dr. Henk Lamberts and Dr. Maurice Wood, members of WICC and published by Oxford University Press. Other titles had previously been given to this project, namely International Classification of Primary Care and Reason for Encounter Classification. Finally it was published as ICPC under the auspices of WONCA.

The International Classification of Process in Primary Care, IC Process PC, was produced by the Committee with the cooperation of the North American Primary Care Research Group (NAPCRG) and published in 1986 by Oxford University Press.
A classification of Functional Status was at the time being proposed, but there was some difficulty to develop an instrument which could be used to assess functional status as against classifying the elements which needed to be included in an assessment of functional status. In 1986 the committee agreed to explore the feasibility of a Classification of Objective Findings.

All these activities required frequent meetings, the funding of which was always a problem. Of their own initiative the committee managed meetings in London funded by the Rockefeller Foundation and in Germany by the Volkswagen Foundation. As further assistance it was confirmed in 1986 that all associated royalties should be earmarked for funding of committee meetings.

In 1989 the committee was aiming to produce a comprehensive International Classification for Primary Care – ICPC, but enlarged to include: -inclusion and exclusion criteria for diagnostic titles -an expansion of process items in primary care: in particular a classification of drugs – and the inclusion of functional status assessment information. Entailed in this was the need to review and update the inclusion and exclusion criteria in ICHPPC-2 Defined, a task undertaken by Dr. Lamberts and Dr. Wood by spending a month at the Bellagio Study Centre of the Rockefeller Foundation. Other members of the committee accepted responsibility for other segments of ICHPPC-2 Defined. Also ICD 10 was being prepared by WHO and considerable work was being done to align the WONCA classifications and publications to this. Another matter of some concern to the Executive was the fact that the National Health Service in UK had adopted the Read Clinical Classification, developed by Dr. James Read, a general practitioner.

The work to develop the comprehensive classification of primary care finally came to fruition in 1998, nearly ten years after it started, under WICC Chair Prof. Neils Bentsen. ICPC-2 was published by Oxford University Press in 1998, and was accepted within the World Health Organization’s (WHO) Family of International Classifications. In 2000 an electronic version was developed and released, and was a useful opportunity to correct minor errors in ICPC-2 which had been pointed out by users in the two years since its release.

ICPC-2 has been updated regularly since its release in 1998, both in realigning its definitions and inclusions/exclusions to changes in the conceptualisation of health problems and diseases, and also in keeping the mapping to WHO’s ICD-10 up to date and accurate. Much of this work has been done with the support of WHO collaborating institutes, such as those in Norway and Nijmegen in the Netherlands.

In 2005, a revised book with the most up-to-date version of ICPC-2 was published by Oxford University Press as ICPC-2-R. This also included a CD-ROM from Prof. Lamberts’ Dutch Transition Project, one of the most important longitudinal family medicine studies based on ICPC, and a Thesaurus mapping many thousands of terms to both ICPC-2 and ICD-10 developed by Prof. Lamberts along with WICC collaborators Dr. Inge Okkes and Dr. Kees van Boven, and Dr. Sibo Oskam and Dr. Henk Becker from the University of Amsterdam.

Immediately after the publication of ICPC-2-R, it was agreed that there was now a need for a major revision of ICPC-3. Changes in the way family medicine, and medicine in general, were conceptualised and recorded required more radical revision than yearly updates could reasonably handle, and the very structure of ICPC-2 might have to be adjusted or changed. The idea was also to collaborate with WHO and make the development of ICPC-3 more harmonious with that of ICD-11. However, this proved very difficult in practice, since WHO might not have fully appreciated the importance of the delicate balance between recording reasons for encounter, process of care and health problems together, essential for any diagnostic research or diagnostic decision support system.

In the past ten to eleven years, the development of ICPC-3 has dominated the agenda for WICC meetings, under the chairmanship of Prof. Mike Klinkman from the USA, and now Prof. Thomas Kuhlein from Germany. A major step forwards was the creation of a consortium of colleges of family medicine and interested organisations in collaboration with Wonca and led by the University of Nijmegen through the person of WICC member Dr. Kees van Boven, to fund the work involved. The work on ICPC-3 has been performed by groups of WICC members who worked on each individual chapter, co-ordinated mainly by Prof. Helena Britt from Australia, on the strength of her decades of experience of ICPC research in the BEACH project. Recently this editorial work has been co-ordinated by a specific WICC task group under her lead, now chaired by Dr. Jean Karl Soler from Malta.

Edited and updated from an original WICC History between 1972 and 1992 by Prof. D. Game
Jean K Soler, Malta, February 2019