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.
Distinguish between Primary Care and Primary Health Care:
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:
- Primary care was originally delivered in Canada by individual physicians providing fee-for-service care.
- Concern over patients who could not afford to pay led to the introduction of universal care funded by government: "private practice, public payment".
- As costs of care rose, governments sought more control over its delivery, since they had to foot the bill.
- Other criticisms included the lack of continuity of service; focus on acute care not prevention, and shortage of physicians. Similar critiques were made in Britain and in the U.S.
- Reforms were proposed along three main lines: promoting inter-professional health care teams; patient rostering (physicians keep a list of patients for whom they provide on-going care); and finding a remuneration system other than fee-for-service.
- The criticisms of fee-for-service payment are that it encourages physician-driven provision of care; it biases care toward acute conditions that can be diagnosed and treated quickly and away from complex cases; it also makes overall costs rather unpredictable.
- In Ontario, several developments took place. During the 1970s, Health Service Organizations and Community Health Centres were proposed. During the 1980s there were experiments with broadening the range of professionals covered under primary care - such as nurse practitioners. During the 1990s there were a series of primary care pilot projects that have led to the current range of primary care models (see below).
- Here is a comparison of characteristics of different approaches to delivering primary care in Ontario, as of 2010:
Fee for Service System Health Service Organizations (since 1975) Community Health Centres
(began c. 1980)
Family Health Networks
Family Health Groups
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
160 146 393 2,536 184 Physician remuneration FFS Capitation Salary FFS, blended FFS + bonuses Capitation or salary Patient rosters? No 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:
- Viable projects are typically narrow in scope. The family practice should focus attention on a single consensus initiative at a time and not take on too many contrasting projects.
- Form a team to lead the COPC activity. This should include clinicians and non-clinician staff members from the practice and community representatives.
- Define the community to be served.
- Use both quantitative and qualitative data (e.g. community opinion) to identify health issues that are candidates for intervention.
- Review and prioritize the various candidate problems; community participation is important.
- Analyze the problem and identify the available strategies for addressing it and choose a workable intervention, given the resources you have.
- Evaluation is essential to informing the planning for future COPC activities. This will provide the basis for a reassessment of the priorities and the continuation of the COPC process in the defined community.
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:
|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'.
(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.
Updated June 14, 2016
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