Primary care fit for the future needs to be…
Comprehensive: The organization is accountable for meeting the majority of patients’ physical and mental healthcare needs, including: wellness, prevention, acute care and chronic care. Where the right skills or services are not available within the primary care organization, staff play a central role in coordinating virtual care teams involving professionals from other community services and specialists in secondary care and signposting people to relevant local welfare and other social support services.
Person-centered: This is relationship-based, premised on trust and concerned about the whole person. Patients and their carers are recognized as core participants in decision-making about care and treatment. When registered with a primary care organization the patient benefits from continuity of care with a professional. Person-centered care also recognizes the impact of broader life experiences (such as wealth, housing and family circumstances) on an individual’s health and care.
Population-oriented: The organization is responsible for providing services not only to those who attend their premises, but also for a specified population. Depending on the model in question, this might include: all individuals registered with the organization, all those who are resident in a specific geographic area and/or individuals who belong to a specific population group (e.g. the frail elderly or homeless).
Coordinated: Care is coordinated across all elements of the healthcare system, with particular attention paid to overseeing and being accountable for transitions between providers, and building and sustaining open and clear coordination between the patient and their various care teams.
Accessible: Appropriate waiting times for initial consultation and advice, diagnosis and care. Patients have 24/7 access to medical and nursing advice and care and organizations are responsive to patient preferences around access.
Safe and high quality: Care is evidence-based whenever possible, and clinical decisions are informed by peer support and review. Clinical data are shared within the organization to inform quality assurance and improvement. The organization is financially sustainable, such that safety and quality standards will not be compromised by resource pressures.
And sustainable in terms of:
- public trust
- fit with wider health system.
The design principles explored in this report can be applied in various ways and need to be adapted to the context of different systems and localities. Those that relate to the nature of a clinician-patient consultation could be applied immediately into primary care in many countries, irrespective of the wider policy and financial context. Those that relate to access to wider services – such as diagnostics and specialists – and to population health may need additional resources and changes in professional education and regulations before they can be applied.
The design principles aim are consistent with some directions of travel illustrated in our case studies and could help to shape a new approach to primary care. Our case studies, and conference findings suggest that primary care systems will need to:
- Be larger.
- Have access to a wider range of professionals as part of the team or working alongside them.
- Offer a better organized out of hours service.
- Provide better continuity to those patients that need it most.
Models that follow this logic will be better placed to go beyond traditional primary care and develop more ‘integrated care’. This creates the opportunity for them to take on risk sharing and capitation budgets – as outlined in the journey to accountable care organizations envisaged in the US – the diagram on the right from United Healthcare illustrates this.
The challenge for payers, regulators and governments is how to create a set of incentives that support innovation, experimentation and evolution, that hold providers firmly to account but without unintended adverse consequences, bureaucracy and box ticking.
These approaches may allow many different solutions and be permissive on many things but will need to be tight on governance, open book accounts, key outcomes and issues such as conflict of interest. They may have some tight process requirements too. Walking the line between these difficult compromises is the key to success.
The ideas in this paper suggest that it may be possible to combine a number of characteristics which may appear to be hard to reconcile. A way needs to be found to have the best relationship based primary care with continuity for those that value it, as well as rapid and convenient access for those for whom it is important. There is a need to retain the benefits of generalism and longitudinal relationships while offering patients more specialist opinions and clinicians able to deal with complex problems such as the care of the frail elderly.
The models in this report are looking for ways to get the best of the biomedical and social models of care: to be excellent in treating both the condition and whole person. We think this is possible but it requires some major changes while at the same time protecting what has made primary care successful and valued.
Greater scale, more standardization, the inclusion of specialist expertise and bringing in social care and other community services are a key starting point. Leadership from within the profession is vital. Bold experimentation building on what works is required to help services evolve to meet a new set of difficult challenges.