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Primary Care: Definitions and Historical Developments
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1. Core Knowledge:

Primary care refers to first-contact care, in which the majority of health problems are treated.  It is the foundation of any health care system, and nations with strong primary care seem to have better health than those without.  

Definitions:
Distinguish between Primary Care and Primary Health Care:
Logo for primary health care, Aolma Ata declaration
Primary Care often describes a narrow concept of “family doctor-type” services delivered to individual patients.
But it can also apply to all first-contact care, including emergency room visits.
Primary Health Care is a broader concept. In addition to primary care services, it includes health promotion and disease prevention, and also population-level public health functions.  It reflects the approach to service provision for a community proposed in the WHO 1978 Alma Ata Declaration.

 

 


2. Nice to Know:

Some History

 
Fee for Service or Comprehensive Care model
Health Service Organizations (since 1975)
Community Health Centres
(began c. 1980)
Family Health Networks
(since 2001)
Family Health Groups
(since 2003)
Family Health
Teams
(since 2004)
Description Solo family physicians 3+ physicians working in close proximity Interdisciplinary teams working for hard-ro-serve populations; focus on social determinants 3+ physicians working in a group; extended hours coverage 3+ physicians working in close proximity Physicians work in interdisciplinary teams
Number of Groups 7,439
physicians
160 146 393 2,536 184
Physician remuneration
FFS
Capitation
Blended capitation model
FFS, blended
FFS + bonuses
Blended capitation model
Patient rosters?
Optional
Yes
No
Yes
Yes
Yes
Group practice
Optional
Mandatory
Mandatory
Mandatory
Mandatory
Mandatory
24/7 access?
Optional
Mandatory
Mandatory
Mandatory
Mandatory
Mandatory
Funding for other care providers?
None
Some
Significant
Some
Some
Significant

Source: Dr. W. Hogg, C.T. Lamont Primary Health Care Research Centre, Elisabeth Bruyère Research Centre, Ottawa.

Primary care in Ontario has become very complex as the government struggles to reform it!   Practice settings in Ontario currently include:

 

 

 


3. Additional Information:

Community-Oriented Primary Care (COPC)

COPC was a movement that encouraged primary care practices to provide accessible, comprehensive, coordinated and continuing care to a defined community. The ‘community’ can be defined geographically or socially: groups within a workplace, school or neighbourhood. It does not refer simply to the patients who happen to use you as their physician. COPC begins with defining and characterizing the community and getting them involved in conducting a community diagnosis and developing and implementing an intervention. The final stage is to monitor the impact of intervention, cycling back to re-defining community needs.  This systematic approach to providing care for a defined population came from work in the 1930s by Will Pickles in England and Sidney Kark in South Africa.  
For a historical review see Longlett SK et al: Community-Oriented Primary Care: historical perspective. J Am Board Fam Pract 2001; 14:54-63.

Mullan and Epstein offer more detail:

Mullan F, Epstein L. Community-Oriented Primary Care: New Relevance in a Changing World. Am J Public Health 2002; 92(11): 1748-55.

Here are some more detailed definitions of primary care:

Primary Care
Canadian Medical Association, 1994 (1) "Primary medical care consists of first-contact assessment of a patient and the provision of continuing care for a wide range of health concerns. The scope of primary care includes the diagnosis, treatment and management of health problems; prevention and health promotion; and ongoing support, with family and community intervention where needed."
Barbara Starfield, 1998 (2) Primary Care is the “level of a health service system that provides entry into the system for all new needs and problems, provides person-focused (not disease-oriented) care over time, provides care for all but very uncommon or unusual conditions, and co-ordinates or integrates care provided elsewhere by others.”
Institute of Medicine (IOM) Committee on the Future of Primary Care, 1996 (3) 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 practicing in the context of the family and the community.
Primary Health Care
Ontario Health Services Restructuring Commission, Primary Health Care Strategy, 1999 (4) The first level of care and usually the first point of contact that people have with the health care system. PHC supports individuals and families to make the best decisions for their health. It includes advice on health promotion and disease prevention, health assessments, diagnosis and treatment of episodic and chronic conditions and supportive and rehabilitative care. Services are co-ordinated, accessible to all consumers and are provided by health care professionals who have the right skills to meet the needs of individuals and the communities being served. These professionals work in partnership with consumers and facilitate their use of other health related services when needed.
Canadian Health Services Research Foundation, 2003 (5) Primary Health Care is defined as a set of universally accessible first-level services that promote health, prevent disease, and provide diagnostic, curative, rehabilitative, supportive and palliative services.
The WHO Alma Ata declaration, 1978 Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain (. . .)   It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process
WONCA: The European Definition of Primary Care, 2002
WONCA stands for the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians.
It lists a number of defining standards, such as
   'point of first medical contact within the health system'
   'manages illness at an early stage in its development'
   'establishes a relationship with the patient over time'
   'promotes health and well-being both by appropriate and effective prevention'
   'deals with health problems in their physical, psychological, social, cultural and existential dimensions'.

Sources:

(1) Canadian medical Association. Strengthening the foundation: the role of the physician in primary health care in Canada. Ottawa, CMA, 1994.
(2) Starfield, B. Primary Care: balancing health needs, services and technology. 2nd ed. New York: Oxford University Press; 1998. pp 8-9.
(3) Molla S, Donaldson K, Yordy D, Lohr KN, Vanselow NA, eds. Primary Care: America’s Health in a New Era. Report of a Study by a Committee of the Institute of Medicine, Division of Health Care Services. National Academy Press, 1996, 395 pp.
(4) Ontario Health Services Restructuring Commission. Primary Health Care Strategy. Advice and Recommendations to Hon Elizabeth Witmer, Minister of Health, December, 1999. www.health.gov.on.ca/hsrc/phase2/rr_phc_final.doc .
(5) Lamarche PA, Beaulieu M-D, et al. Choices for Change: the path for restructuring primary health care services in Canada. Report submitted to the Canadian Health Services Research Foundation, 2003.

 

Links: Criteria for judging the quality of primary care
            Dr. Ponka's report on Top Ten Diagnoses in primary care
            Dr. Spasoff's notes on primary health care
            PPT slides on primary health care
            CANMEDS 2000: the roles of the contemporary physician
            Romanow report (which talks of primary care)

            Here is series of six articles in the BMJ on core values of primary care:

1.   Goss  Brian M., 1998.Primary care: core values Contracting for general practice: another turn of the wheel of history

2.      Dixon Jennifer, Holland Peter, Mays  Nicholas, 1998, Primary care: core values Developing primary care: gatekeeping, commissioning, and managed care

3.      Roberts John, 1998, Primary care: core values Primary care in an imperfect market

4.      Neuberger Julia, 1998, Primary care: core values Patients' priorities

5.      McWhinney Ian R.,1998, Primary care: core values Core values in a changing world

6.      Toop Less, 1998, Primary care: core values Patient centred primary care

 

Updated February 10, 2017