Primary care VS Primary health care? And who cares?

On Budget night, Croakey was interested to see references in the Government’s announcements to primary care and primary health care as if they are interchangeable terms.

But I must confess to feeling a bit like the kettle who blackened the pot as I’m sure I’ve been guilty of similar myself. And so have plenty of others.

So I’ve asked a bunch of people with an interest in such matters about how they distinguish between primary care and primary health care. And whether it’s worth drawing the distinction. And, if so – why does it matter?

Gordon Gregory, executive director of the National Rural Health Alliance, kicks off the discussion, giving us some background about the history of primary care and primary health care, and why we should be concerned that so much of the health reform focus is on primary care. This may not be the best way to improve health outcomes, he argues.

He writes:

“For people in the health sector, the most common reference point for drawing a distinction between ‘primary care’ and ‘primary health care’ is the Declaration from the International Conference on Primary Health Care held in September 1978 in Alma-Ata.

Reading that Declaration now, and as a relative newcomer to the health sector, it seems that the main purpose of that Declaration was to state and promote some of the key principles for national and international efforts to make good health and health services available to all the world’s citizens.  The clearest and strongest messages in the Declaration are that health is a human right to which international commitments should be made, and that “people have the right and duty to participate individually and collectively in the planning and implementation of their health care”.

It is only in the margins of the Declaration, as it were, that the point is made that health status is determined to a significant extent by such things as access to education and fresh water, rather than by access to health services per se.

Part 1 of the Declaration includes:

“ –  the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.” (emphasis added)

That part of the declaration (VI) which explicitly defines primary health care does not include any reference to those individuals or professions providing health services, nor to what (these days) would be regarded as the social and economic determinants of health.  Rather, it refers to the methods and technology by which health care is made available, and to the participatory, affordability and locality aspects of such care.

Part VII includes:

“Primary health care – – includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;

involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors.”

Much has been made of this marginal matter, and a whole generation of health professionals seem to have a favourable if somewhat imprecise view of what the Alma-Ata Declaration says about the breadth of the determinants of health.

Perhaps one of the reasons for this ‘positive press’ is that the Declaration spells out very clearly that health services are delivered by a wide range of health professionals:

“(Primary health care) – –  relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.”

Historians of the health professions might be able to say what the status was in 1978 of the balance between medicine, on the one hand, and all other health professions, on the other.  It seems likely that one of the reasons why nurses, allied health professionals and others adhere strongly to the Declaration is that it was a critical and high-status affirmation of the proper place of non-medical health professionals in providing health services.

The Alma-Ata Declaration provides only an imprecise distinction between the two terms – and does not go very far in defining the range of policy matter which impacts on health status.  However there is very considerable value in clinging to the distinction and making it more rather than less clear.

That value resides in the utility of us continually reminding ourselves – as a nation, as health professionals, as citizens and health consumers – that we cannot and should not rely on the health system for long life and  wellbeing.

We should recognise that those who are born poor or with a disability will need our help as individuals and as a society to give them a fair chance at equivalent health.  As individuals we must recognise that our own actions play a large part in determining our lifetime health trajectory.  As taxpayers we should recognise that investments in health-promoting infrastructure, in food distribution and quality, and in employment programs and regional development can be viewed as investments in the nation’s health, just as much as the money spent on hospitals and health professionals.

The term ‘primary health care’, if properly nurtured, can act as a useful rallying-cry or lightning rod for such positions and attitudes.  It can remind us of the need not to medicalise health conditions; to focus on wellness rather than illness; and to support investment in universal education, an income safety net, equal employment opportunity and so much more.

And with a little care in language and communication, the distinctions can be easily maintained.

The term ‘primary health care’ is the larger phrase (it has three words, not two) and stands for the bigger picture.  ‘Primary care’ is provided when a health professional interacts in a planned and scheduled way with a patient.

A 2002 World Health Organisation meeting on Primary Care, Family Medicine and General Practice in Barcelona defined primary care as:

”a span or an assembly of first-contact health care services directly accessible to the public”.

Helen Keleher, in the Australian Journal of Primary Health in 2001, wrote that:

“primary care more often than not involves a single service or intermittent management of a person’s specific illness or disease condition in a service that is typically contained to a time-limited appointment”.

One of the reasons for the confusion  between the terms is that primary care professionals are proud of the primary health care work they do – for instance, through providing broad advice on health and fitness when dealing with a patient’s specific illness or disease.  Beware the commentator who dares suggest that a doctor or a nurse does not do or is not capable of doing primary health care!

Another reason is that, uttered in a dark room as the opening gambit in a conversation ie with the listener having no clue as to context – the term ‘primary care’ could mean many different things.  In this context the practice should be to use the term ‘primary care in the health sector’ or ‘primary care in health’.

In a context which is clearly already about health, like a health textbook or a paper in a health journal or about health issues, there is no need to add the word ‘health’ to ‘primary care’ and so confuse the issue.

With greater care and clarity, when the government of the day establishes a task force to plan for better and fairer access to health professionals, one can be confident it will be a primary care strategy.

And wouldn’t it be a great step forward to aspire to a national primary health care strategy: a national approach to whole-of-government action  to improve health and wellbeing.  Terms like ‘whole of government’ slip off the tongue so easily but describe approaches to public policy which are inherently difficult to put into operation.

The current round of health reform relates almost exclusively to primary care.  Yet reform of primary care in health may be a relatively ineffective way to improve health outcomes.

More important are housing in the community for the homeless and those with mental illness, a national food distribution and affordability program, taxation policies to reduce the disparities in income and asset levels, innovative programs to improve school retention rates where they are low, community development programs to support sustainability of smaller communities, canny ways to implement research findings into public health policies - and so the list goes on.

No one likes to be put into a box, particularly if it is too small.  People who are good at primary care should not be thought of as narrow in their capacities or practices.

And it is those primary care professionals who should lead from the inside towards a clearer understanding of what primary health care really means."

• Stay tuned for more Croakey posts on these issues….