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A surprising lack of clarity around the definition of core primary health care services

“The implementation of primary health care (PHC) may well be one of the most significant systemic and ideological health reforms of modern times. Countries with stronger PHC systems have demonstrably more efficient, effective, and equitable health care. Primary health care can be considered a philosophy, an approach to the delivery and development of services and first contact health services. It is based on a social, rather than biomedical, model of health, with accessibility to and affordability of service as primary objectives.”

That is the powerful opening statement to a new systematic review investigating what are the core primary health care services that Australians living in rural and remote areas should be able to access.

Thanks to one of the researchers, Associate Professor Tim Carey, for reporting on the findings (which you can also read in full in BMC Health Services Research).

The review raises the tantalising question: if these core services can be identified, will this provide some obligation on funders to ensure they are available and accessible?

****

What primary health care services should residents of rural and remote Australia be able to access?

Tim Carey writes:

The disparity in health outcomes between rural and remote Australians compared to their metropolitan counterparts is well established.

One way of helping to reduce this disparity is to have a clear idea of those primary care services that should be considered “core” or essential to any health service regardless of locality.

In metropolitan areas where a wide range of services is readily available, demarcating core services might not be necessary. In rural and remote places, however, where populations are dispersed, what services are most essential and how those services should be delivered are issues of fundamental importance.

A systematic review was undertaken to identify the services that could reasonably be considered “core”. That is, we wanted to find out what the essential package of primary care services were that any Australian, regardless of geography, had a right to expect access to.

We were also interested in understanding the methodology by which any particular researcher or research group arrived at a selection of core services.

The results surprised us.

Despite searching established databases as well as relevant websites and also contacting national and international experts, we could find no readily agreed set of core services.  Indeed, in some places like the UK and New Zealand, it appeared that governments had explicitly avoided defining core services.

Perhaps there are important fiscal implications for articulating a suite of core services: once the core services are identified there is then an obligation to ensure access to these services is efficient and straightforward for all.

Just as there was no readily defined set of core or essential services, there was also no common methodology. The methodologies varied, as did the purposes for which these methodologies were employed.

Terms also varied. In some instances, for example, the terms “functions” and “services” seemed to be used interchangeably. The marked variability in purposes and methodology meant that services as diverse as “water and sanitation” and “microscopic examination of urine” were captured in our review.

Without consensus in the literature to guide us, we synthesised the results by generating a matrix outlining the possible dimensions of primary care services and the demarcations within these dimensions.

One dimension, for example, was “Function of service” with the demarcations “getting people better” and “keeping people well”. Another dimension was “Aspect of body” with the demarcations “physical”, “mental”, and “dental”.

The matrix could be useful in different ways. The matrix could be used, for example, to assess the current service provision in a locality. It could also be used to plan required services in the future. After a reorganisation of services the matrix could also be used to help evaluate service provision.

With the matrix, service planners, health managers, and policy makers might be able to work more closely with communities to make sure that communities are receiving the necessary services in a way that is efficient and effective.

As a consequence, we may begin to see a reduction in the current separation of health outcomes between Australian citizens who live in metropolitan centres and those who reside in rural and remote locations.

•  Tim Carey is Deputy Director, Head of Research at the Centre for Remote Health, a joint centre of Flinders University and Charles Darwin University, and holds positions with the Central Australian Mental Health Service and Centre of Research Excellence in Rural and Remote Primary Health Care

• “What primary health care services should residents of rural and remote Australia be able to access? A systematic review of “core” primary health care services”, by Tim Carey, John Wakerman, John Humphreys, Penny Buykx and Melissa Lindeman.  http://www.biomedcentral.com/1472-6963/13/178/abstract

 

 

 

 

 

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