‘…a paradoxical situation: the tension between the relative weakness and unattractiveness of this level care versus the intention to assign critical strategic functions to it.’
From: Primary Care In the Driver’s Seat?
Saltman, Rico and Boerma (eds) 2006
Saltman and others (2006) have argued that the intermediate territory between self-care and specialist/hospital care is changing, with primary care playing an increasing part in coordination and integration of care that is provided by different services. These new roles, together with elements of specialist care that can now be delivered in primary care settings, can be thought of as ‘extended primary care’. They are the focus of recent developments in many European countries, often seeking to bridge the divide between generalist first contact care, specialist services and disability or home care.
Very often primary care:
- is delivered by small independent practices with limited access to a wider multidisciplinary team;
- is based on a model of inflexible and short appointment slots only available from Monday to Friday within normal working hours;
- is unable to offer telephone, email, skype or other modern access to medical and nursing advice;
- has inadequate diagnostic support; and
- is insufficiently connected to specialists, community based services (e.g. pharmacy) and other resources that could help it function more effectively.
Changes in the patterns of disease, expectations, workforce and across the whole of healthcare means that primary care needs to change.
This report presents the results of discussions with primary care experts from across Europe brought together in Brussels by the Nuffield Trust and KPMG.
Effective primary care enables improved health outcomes and lower costs (Starfield et al, 2005; Atun, 2004). Recent research has concluded that strong primary care is associated with lower rates of avoidable admissions to hospital and fewer potential years of life lost. The same research points out that primary care requires higher levels of health spending to achieve such benefits, with likely savings accruing in the longer (not short) term (Kringos and others, 2013).
Primary care is playing an increasing role in care co-ordination across sectors (Saltman et al, 2006), although concerns remain about its ability to fulfil this role without parallel investment in integrated patient records and IT , the aligning of financial incentives across health providers, and the development of effective governance arrangements (Rosen et al, 2011).
Primary care has the potential to be the supporter of IT-driven services such as telehealth and telecare and on-line consultations. This requires the parallel development of new models of service delivery, and experience from rural and remote areas in countries such as Australia and Canada, is of particular relevance here. While evidence for telehealth and telecare in countries such as the UK where the interventions have been aimed directly at patients has proved equivocal to date, the technology and knowledge about how to apply it is changing very rapidly. Technology that supports consultation between professionals seems to be helpful in providing specialist support to clinicians.
Primary care lies between self-care and hospital (or specialist care) and fulfils a range of functions:
- prevention and screening
- assessment of undifferentiated symptoms
- triage and onward referral
- care coordination for people with long-term conditions
- treatment of episodic illness
- provision of palliative care.
Richard Bohmer points out that the different functions listed above can be divided up between different providers, depending on the history and configuration of a particular health and care system.
This may be necessary if there is not an existing strong family doctor system or parts of it are not delivering as required. The family doctor model has proved a successful way of bringing these components together, but there are growing challenges which are putting strain on that model.
There is increasing interest in many health systems in primary care working on a population health management approach, whereby primary care organizations take responsibility for the health of a register of people, addressing the prevention of ill health as well as presenting illnesses.