The term “Primary Care” is thought to date back to about 1920, when the Dawson Report was released in the United Kingdom. That report, an official “white paper,” mentioned “primary health care centres,” intended to become the hub of regionalized services in that country. (ref)
One definition is
“the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practising in the context of family and community.”
Outcomes
There is good evidence that high quality Primary Care improves outcomes. Tertiary Care is expensive and in contrast, does not improve outcomes – it may even be harmful (1)
Six mechanisms, alone and in combination, may account for the beneficial impact of primary care on population health. They are (1) greater access to needed services, (2) better quality of care, (3) a greater focus on prevention, (4) early management of health problems, (5) the cumulative effect of the main primary care delivery characteristics, and (6) the role of primary care in reducing unnecessary and potentially harmful specialist care.
Preventive interventions are best when they are not related to any one disease or organ system. Eg cessation of smoking, wearing of seatbelts and physical exercise. The benefits of these interventions are clear. It is more difficult to show benefit from screening for specific diseases, though many interventions have been proposed. The idea that a checkup and early detection of various diseases will change the outcome is promoted regularly in popular media. But there is no convincing evidence that a regular checkup improves outcomes (see my previous article).
Equity is important – cost to the consumer reduces equity.
Primary care has a greater impact in improving outcomes in lower socioeconomic groups.
Specialist and tertiary services have either no effect or an adverse effect on overall outcomes. But access to hospitals and tertiary care is political “hot button” issue – politicians find it difficult to resist such pressure.
There is good evidence that patients attending a specialist directly are more likely to have unnecessary hospital admissions and poor outcomes than those seeing a Primary care physician first. (3)
There is a good theoretical basis for this – a specialist used to hospital practice over-estimates the rate of abnormality in a Primary Care population when planning intervention or investigation – ie the “pretest probability” in hospital patients is different to the probability in a Primary Care population. This affects the “sensitivity” and “specificity” of the intervention.
WHO paper on Primary Care (2008) (2)
This paper describes several models of service delivery in Primary care.
“Medical” model.
In this approach, the client interacts intermittently with the service in treating or managing specific diseases or issues – the service has responsibility limited to the condition being managed for the client during an episode of care.
“Program” Model
Programs target a specific area of the client or population Health – eg Chronic Disease, Trachoma, Rheumatic Heart Disease. The client’s Health Care is broken into “parts” and different clinicians deal with one area. Care may become fragmented and it is important to communicate between various providers/clinicians. Often the record systems in use are not up to the task or there may even be “silos” between record systems. Responsibility for the client is limited to the condition being managed by the program.
Holistic Model
The Clinician or service takes responsibility for the client from birth to death and manages all their issues including advocating in “nonmedical” issues such as housing and employment. This is regarded by the WHO as the most effective approach.
In practice most Primary Care services in Australia are a combination of the first and second models – it is rare to see the third model.
Generalist vs Specialist Care
If we accept that an “Holistic” model is best and most effective, and that Care should be fragmented as little as possible, then the Clinician delivering the care must have a broad knowledge and scope of practice. He/she must be able to deal with all ages and be able to cope with presentations across many clinical domains. Specialists deal well with their area of specialty but poorly otherwise. Current systems devalue the Generalist with many tasks they have previously performed being taken up by various specialities. (eg normal childbirth). Common conditions formerly dealt with by a GP are now routinely referred. This is inefficient and expensive and may result in poorer outcomes (see above).
Continuity – the value of a relationship
Continuity is one of the principal pillars of good Primary Care. The Clinician has a relationship with the client and knows their history and family background. There is good evidence that this improves outcomes and saves money.
“Among other improvements, continuity of care leads to a higher quality of care, more preventive care, decreased emergency department visits, and reduced odds of avoidable hospitalization.”(ref)
Hospital systems deal with episodic illness on the whole – they “live in the now” and cope poorly with the requirements of ongoing care in complex chronic illness.
Complexity and multimorbidity
Primary Care is increasingly managing clients with many different issues. The Single Issue “cure” approach is no longer valid in these cases. We must become skilled at managing Complexity and adopt a different approach – incremental and iterative and accept that we cannot “solve” most of the issues. (See my article on Complexity). Continuity is critical here.
What is happening now?
Commercialization
In Third World countries where Governments have not controlled the delivery of Primary Care and resources are limited, delivery has become dominated by commercial providers. Clients bear much if not all the cost. There is a proliferation of ineffective treatments and a reduction in quality. Equity is reduced and the “Inverse Effect” dominates – ie most of the care goes to those who can afford it but need it least.
In Western countries such as Australia this effect has been less, but Governments struggle with the cost of programs such as Medicare. Commercial providers have exploited the open access nature of Medicare, with the result that Government has imposed more and more complex rules and barriers to save costs. Subsidies such as Rebates have not kept up with costs and “the Gap” paid by clients has steadily increased. Specialist services are essentially no longer Bulk Billed and the rate of Bulk Billing in GP services is declining. Equity and access has declined as a result, where the Australian health system was once regarded as having excellent equity as a reasonable cost. New and expensive drugs and treatments appear regularly – Governments struggle to fund these. Medical Evidence has probably become corrupted (see my previous article).
General Practice in Australia
General Practice was the principal provider of Primary Care services in Australia in the past. But some believe it is in decline, or even in crisis. Various bodies and clinicians are competing in the Primary care space eg nurse practitioners and pharmacists. Various specialists now perform many roles formerly the domain of General Practice – there has been a loss of scope for GPs
In the Health system generally continuity has been devalued. There is acceptance of massive staff turnover in services such as Remote Health. Hospital systems have always been staffed at a junior level by doctors in training who rotate regularly though different posts. Record systems in hospitals are primitive and not up to the task of compensating for this rapid turnover of staff.
Bulk Billing (medical services free to the consumer) and Emergency Department waiting times are political “hot button” issues receiving a lot of attention at present.
The Federal Government recently announced “Acute Care Clinics” – this promotes the idea that most medical presentations are single issue and that continuity is not important. Bulk Billing incentives were increased but the basic Rebate for GP consultations was left unchanged. The Health Minister (!!) urged consumers to “shop around” for a Bulk Billing clinic so they could avoid paying a gap fee. While cost is important to equity, this statement ignores the value of continuity. It appears the Health Minister does not understand this. Governments have been unwilling to increase Rebates to keep Gap costs down, instead relying on Bulk Billing incentives. Complex illness takes more time and requires sophisticated clinical skills to manage. These clients are generally less able to pay for services but the Rebates for longer consultations are effectively less.
The GP is increasingly required to perform bureaucratic tasks, generally involving access to various expensive resources. There is also an increase in “legal” tasks such as licensing medicals and certificates. These consultations have three parties involved – the GP, the client and another body paying the cost or requiring the report or certificate. The GP has two relationships and duties – one to the client and one to the third party. These relationships may be in conflict and cause “moral ambiguity”– a conflict which the GP must manage.
Conclusion
Good Primary Care is effective in improving outcomes and economical of resources.
The principal elements of Primary Care are “Expert Generalism” and Continuity. Complexity is an increasing challenge which requires a new approach and calls on a Generalist Knowledge and a relationship with the client.
But the traditional model of Primary Care in Australia is under threat. GPs face more complexity for less money, competition from other providers, an increase in nonmedical tasks and a downgrading of clinical scope. Policy makers and politicians appear unaware of these challenges.
References
(1) Milbank Q. 2005 Sep; 83(3): 457–502.
Contribution of Primary Care to Health Systems and Health
Barbara Starfield, Leiyu Shi, and James Macinko
(2) The World Health Report 2008 Primary Health Care WHO
(3) Can Fam Physician. 2021 Sep; 67(9): 679–688.
Why does continuity of care with family doctors matter?
Review and qualitative synthesis of patient and physician perspectives
Dominik Alex Nowak, MD MHSc CCFP, Natasha Yasmin Sheikhan, MPH MHS
Sumana Christina Naidu, BHSc Kerry Kuluski, MSW PhD
Ross E.G. Upshur, MD MSc MCFP FRCPC
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