‘Everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including food, clothing, housing and medical care and necessary social services’
Article 25 of the Universal Declaration on Human Rights
Right away we can see that everyone has the right to basic healthcare - except that 50% of the world’s population do not (WHO, 1978). This figure includes people in both developed and developing nations.
Access to primary healthcare is important as, per dollar spent, it is the most efficient form of care in terms of outcomes such as overall mortality and infant mortality. (Starfield, 1994)
Improving primary care is therefore the WHO preferred method for improving global health in order to achieve health for all (WHO, 1978).
But what are the principles of primary care that make it so efficient? Little is known about this, and it is these questions that we will be exploring on this course.
There are several terms in use that can cause confusion; in Europe, medicine carried out by doctors and nurses in health centres in community settings is known as General Practice. In other countries, this is also known as Family Practice.
Primary care is a slightly different term and refers to all healthcare that is carried out in community settings (doctors, nurses, pharmacists, dentists, volunteers). For the purposes of this course, we will be using the term primary care as in many countries there are very few GPs or Family Practitioners and the majority of care is carried out by others.
Most definitions of primary care make reference to a first point of contact for care, which usually means in a community setting. This can depend on what part of the world you live in and what your health service looks like. The WHO have developed a comprehensive definition that takes this into account and sets out 3 key features of primary care:
meeting people’s health needs through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life course, strategically prioritizing key health care services aimed at individuals and families through primary care and the population through public health functions as the central elements of integrated health services;
systematically addressing the broader determinants of health (including social, economic, environmental, as well as people’s characteristics and behaviours) through evidence-informed public policies and actions across all sectors; and
empowering individuals, families, and communities to optimize their health, as advocates for policies that promote and protect health and well-being, as co-developers of health and social services, and as self-carers and care-givers to others.
Here is another definition used by the Royal College of GPs in the UK:
This second definition introduces two themes of primary care;
1. Care of individuals
2. Care of populations
The definition is taken from a document that also introduces several ‘principles’ that underpin each of the themes. Together, the themes and the principles give an overview of what primary care is about.
Perhaps take a minute to take a look at the document that explains all of this in more detail; it's called ‘Learning General Practice’ (Harding et al., 2018): https://www.rcgp.org.uk/undergraduate
We are going to use this system to organise how we think and compare primary care in different countries. As an overview, here are the principles.
a. The generalist clinical method
The role of evidence in clinical decision-making
Uncertainty in clinical decision-making
Prescribing
b. Holistic care (the biopsychosocial model)
The physiology of holistic care
c. The doctor- patient relationship
Communication with patients of all backgrounds
d. Continuity of care
e. Long term conditions
Diagnostic phase
Maintenance phase
End of life care
f. Emergency conditions
g. Multi-morbidity and complexity
a. The social determinants of health
b. Preventing disease and promoting health
c. Quality of care
d. Information technology
e. Teamwork and leadership
f. Medical ethics
OK, that’s enough reading, now we need to do some thinking
What do you think of these definitions and principles?
How does it fit with your own experiences of primary health care (PHC)?
What features are present and absent where you live?
Finally, what do you think primary care is?
Take some time now to write some thoughts about what primary care is like in your country. We will be using this in the first session we do on the module.
HARDING, A., HAWTHORNE, K. & ROSENTHAL, J. 2018. Teaching General Practice; Guiding Principles for Undergraduate General Practice Curricula in UK Medical Schools, London, Royal College of General Practitioners.
STARFIELD, B. 1994. Is primary care essential? The Lancet, 344, 1129-1133.
WHO. Primary Health Care; Report of the International Conference on Primary Health Care, Alma Ata, USSR, . Health for all 1978 Alma-Ata. Geneva.