Primary care VS primary health care? Who cares? (Part 2)

Gordon Gregory of the National Rural Health Alliance recently kicked off a Croakey discussion on the difference between primary care versus primary health care, and why distinguishing between the two is not simply a matter of pedantry.

Croakey was again reminded of the confusion around these issues when reading the Australia Institute’s recent paper, Do Australians have good access to primary health care? (you can download it here.) The paper tended to equate primary health care with general practice or, at a stretch, nurse practitioners.

Meanwhile, here is how a range of experts distinguish between primary care and primary health care, and whether they think the distinction matters.

Professor Mark Harris, Executive Director Centre for Primary Health Care and Equity

Q: What is the difference between primary care and primary health care?
A: Primary Care is used (mainly in UK and North America) to describe primary medical care or family practice.  Primary Health Care is a broader term encompassing a wider range of providers and services and functions and goals.  There are interminable arguments about definitions.

However a definition of primary health care that we use is outlined below.

In 1978, WHO and UNICEF organised a conference in Alma-Ata in Siberia. This endorsed the concept of “Primary Health Care” (PHC) The he model of PHC was based on following principles:
·        accessibility and fairness (equity);
·        relevance to the needs of the population;
·        cost effective appropriate use of technology and health services;
·        integration between primary care and secondary and tertiary care;
·        encouragement of self care and community involvement in health service planning and provision;
·        collaboration between health and other sectors to address underlying causes of ill health;
·        redistribution of resources to primary care, areas of need, to rural areas, and to disadvantaged groups.

Primary health care in the Australian context can be defined in a number of different ways, both as the first level of care and as a particular approach to care.  Primary health care is often the first level of contact people have with the health system in relation to their health. It is those parts of the health system that focus on protecting and promoting the health of people in communities, and is often engaged in working with issues regarding health in a preventative manner. It is also the place where health problems are commonly identified, managed or referred in the context of early intervention.

Q: Does it matter that these are often used interchangeably? If so, why?
A: Yes. Clearly the broader definition of primary health care encompasses more than primary medical care.  It includes community health services, Aboriginal Health Services and broader preventative programs.  Using them interchangeably may suggest that those components of primary health care other than primary medical care are less important.

Q: Any related comments you’d like to make?
A: Part of this debate has resurfaced recently because of a dispute over the trademark between a chain of medical services and the Divisions of General Practice.

***

Public health policy consultant Margo Saunders

This isn’t my area, but the very thoughtful Professor Helen Keleher (Monash) addressed this very question in 2001 in her article in the Australian Journal of Primary Health, ‘Why primary health care offers a more comprehensive approach for tackling health inequities than primary care’.

She writes:

“Primary care is commonly considered to be a client’s first point of entry into the health system if some sort of active assistance is sought. … Primary care providers are focused on early diagnosis and timely, effective treatment but have greater potential for referral to secondary, non-medical services than has been realised to date. … Primary health care is a strategy of public health, derived from the social model of health and sustained by the Declaration of Alma Ata. … The primary health care sphere of activity extends much more broadly and with different intent, to primary care. Primary health care practitioners work from a social model of health which is partly based on understandings that in order of health gain to occur, people’s basic needs must first be met. … A comprehensive primary health care approach addresses a whole range of social and environmental factors that cause ill-health as well as those that sustain and create good health. … While the primary care sector may find ways of better meeting the illness needs of [Australia’s disadvantaged] population groups, it is a primary health care model that will best address their disadvantage.”

***

Professor John Wakerman, Director, Centre for Remote Health, a joint Centre of Flinders University & Charles Darwin University

Q: What is the difference between primary care and primary health care?
A: Nothing chills my heart more than when, at a tense meeting, a participant turns to me with hard eyes and says: ‘And how do you define Primary Health Care?’ Inevitably, all remaining time and discussion is then expended on this topic, usually by those younger and more patient than me. But it’s really not all that complicated.

Primary Health Care (PHC) was formally born in Alma-Ata (now Almaty, inKazakhstan), in 1978. The Declaration of Alma-Ata defines PHC as:

‘…essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessibleto individuals and families in the community through their fullparticipation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. 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.’

There have been many other definitions crafted since, but the original is as good as any.

In fact, the concept had precursors which by and large embraced the elements of a population approach, community involvement, improved access and a focus on prevention and health promotion. Community Oriented Primary Care was a movement developed in southern Africa in the 1920s and 1930s.  ‘Barefoot doctors’ in China were arguably another expression of enhancing access in an appropriate and affordable fashion.

The first Aboriginal Community Controlled Health Service, arguably an exemplar of PHC, was established through community and professional action in Sydney in 1971.

Following Alma Ata, there was a push back on this politically motivated movement; Selective PHC was painted as an affordable interim measure utilising appropriate contemporary technology, such as immunisation. This was rejected by the true believers as top down, specialist driven and undermining of the political, community-driven nature of true, comprehensive PHC.  We still see many such ‘vertical’ programs, such as disease or organ specific programs, usually critically described as ‘silos’ lacking the sort of horizontal integration that characterizes true PHC.

The key to understanding PHC is that it is used to describe a number of different concepts: the first level of care usually encountered by the population; a range of activities within and outside of the health sector;  a political movement; and a philosophy underpinning service delivery. It is often this last interpretation that applies when dewy-eyed health professionals discuss PHC.

The philosophy is one that emphasizes:

●         Community participation

●         A bottom up approach to planning, implementation & monitoring

●         Health promotion and disease prevention

●         Multidisciplinary practice

●         Intersectoral action

●         Political advocacy

Q: Does it matter that these are often used interchangeably? If so, why?
A: It is important that PHC not be confused with primary care or primary medical care. These refer to the first level of predominantly curative care or the first level of medical, largely curative care, respectively. These are vital elements of PHC, but these terms do not reflect the important political, intersectoral and health promoting elements of PHC.

****

Professor Lesley Barclay, Director, Northern Rivers University Department of Rural Health

Q: What is the difference between primary care and primary health care?
A: Primary health care takes us back to the WHO definitions that are broad ranging and stretch from the first point of contact through to a ‘style’ of working that demonstrates a philosophy of care. Primary care is used in Australia to refer to GP practice and should be targeted at this I believe.

Q: Does it matter that these are often used interchangeably? If so, why?
A: I think they are usefully distinguished terms and should not be used interchangeably though often overlap and are certainly related. Other forms and types of primary health care that can be provided without GP involvement get lost without distinguishing these. For example a key principle of midwifery is to work in a primary health care manner.

Q: Any related comments you’d like to make?
A: It is probably useful to review the aetiology of both terms and revisit these, valuing their correspondance and alingment but also distinguishing their differences.

***

Professor Stephen Leeder, Professor of Public Health, Menzies Centre for Health Policy, University of Sydney

Q: What is the difference between primary care and primary health care?
A:
1.   Primary HEALTH care

The ultimate goal of primary health care is better health for all. WHO has identified five key elements to achieving that goal:

reducing exclusion and social disparities in health (universal coverage reforms);

organizing health services around people’s needs and expectations (service delivery reforms);

integrating health into all sectors (public policy reforms);

pursuing collaborative models of policy dialogue (leadership reforms); and

increasing stakeholder participation.

2.  Primary care is the term for the health services that play a central role in the local community. It refers to the work of health care professionals who act as a first point of consultation for all patients. Such a professional would usually be a general practitioner or family physician, depending on locality. However, at the patient’s discretion and according to their self-assessment of the seriousness of their ailment, they may opt to see another health care professional first, such as a pharmacist, or in some localities (such as the UK), a nurse. The advantage of this approach is that these professionals usually have immediately available access and do not require an appointment. They may then refer either to a primary care physician or to secondary care.

Primary care involves the widest scope of health care, including all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with all manner of acute and chronic physical, mental and social health issues, including multiple chronic diseases. Consequently, a primary care practitioner must possess a wide breadth of knowledge in many areas. Continuity is a key desirable characteristic of primary care, as patients usually prefer to consult the same primary care doctor for routine check-ups, and every time they require an initial consultation about a new complaint. Collaboration among providers is a desirable characteristic of primary care.

Q: Does it matter that these are often used interchangeably? If so, why?
A: It happens so often in Australia, it probably doesn’t matter much but in developing nations where health development is required, primary HEALTH care is highly desirable and preferred.

***

Professor Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity

Q: What is the difference between primary care and primary health care?
A: Primary care is essentially about care for sick or injured individuals based in the community. It is often based around medical care (‘primary medical care’)  but may also involve allied health, nursing care or alternative therapies. Primary health care is broader in that can also deals with the determinants of health – environmental factors (air pollution), social factors (bullying at school), and individual factors (lack of health literacy) – and include a stronger focus on promoting health as well as preventing or treating illness (primary care sometimes involves interventions to prevent specific health problems – immunisation etc.) Primary health care often has stronger links to the community, since it is the communities’ health problems (rather than just individual health problems) that are being addressed. Primary health care involves a more social view of health.

Q: Does it matter that these are often used interchangeably? If so, why?
A: The difference between them matters since primary health care recognises and addresses a broader range of health issues and contributing factors, has a wider range of strategies (more focus on prevention, education, community engagement and capacity building), involves a wider range of players (councils, education, welfare, community organisations as well has health services) and has a philosophy which recognises more easily the contribution which individuals and communities make to their health.  If the terms are used interchangeably, then the ‘extra’ in primary health care is likely to be forgotten, or crowded out by the dominant primary care/primary medical care approach.

***

Dr Lesley Russell, Menzies Centre for Health Policy, University of Sydney:

In 2008 Steve Leeder, George Rubin and I addressed this issue in a paper entitled Preventive health reform: what does it mean for public health? (MJA (2008); 188(12): 715-719).

We saw semantic confusion as one of the current barriers to preventive health reforms.

Here’s what we wrote:

“There is considerable confusion surrounding prevention both as a concept and as an activity. When faced with semantic difficulties, it is important to first rectify the language, as the National Public Health Partnership recommended.

There is inconsistency about whether to use the term “preventative health” or “preventive health”. The federal Health Minister consistently uses the former, although the latter seems to be more common in the literature. More importantly, “preventative health”is sometimes defined in a way that excludes tertiary prevention (see below).

The Australian Institute of Health and Welfare defines prevention as “action to reduce or eliminate the onset, causes, complications or recurrence of disease”. This definition encompasses three forms of prevention:

• Primary prevention limits the incidence of disease and disability by controlling exposure to risk and promoting protective health factors at the population level.

• Secondary prevention comprises measures that aim to reduce the progression of disease through early detection (usually by screening) and early intervention, and is limited largely to at-risk groups in the population.

• Tertiary prevention aims to reduce the negative impact of established disease by restoring function and reducing complications in the affected subset of the population.

However, there are other ways of categorising preventive measures (see Herriot17 and Sindall C and Stratton J, “Perspectives on prevention terminology”, unpublished discussion paper for the SNAP [Smoking, Nutrition, Alcohol and Physical activity] Implementation Group Meeting, June 2003), and there are no clear boundaries between primary, secondary and tertiary prevention.

For example, while public health is defined by the National Public Health Partnership in the same way as primary prevention, public health funding encompasses both primary and secondary prevention activities.

We believe that the key focus of the federal government’s prevention agenda must be on a revitalised public health strategy, using a community-based approach to address the social, political, environmental and economic determinants of health. This primary health care formulation is broader than primary health prevention, and plays a critically important role in dismantling barriers to health and health care and addressing health disparities.

Primary health care is not synonymous with primary care, which is taken to mean the first point of entry into the health system, generally for someone who is sick and seeking treatment. In Australia, primary care is almost always delivered by general practitioners. While there is the potential, increasingly recognised, for primary care to provide preventive and early intervention services, this is not the same as, or sufficient for, the achievement of a comprehensive primary health care agenda.

The principal instruments of primary prevention lie outside the doctor’s office, and require political, social and economic action. The primary prevention of childhood obesity is a classic example of a problem that will not be solved within the medical arena.”

***

Dr Sue Page, Northern Rivers University Department of Rural Health

A quick response: Primary care is whole patient, first contact care that meets the needs of the patients.
Primary Health Care is the extended team and also includes management of the social determinates of health, education etc like the Alma Mater stuff.
As to risks, I note that most of the evidence supporting the benefits of Primary Care is derived from general practice and family medicine rather than any other health professional or even from PHC teams and so can’t necessarily be extrapolated, especially to the team approach when we know that a major cause of hospital based error is poor communication especially around medication and other changes of management.

***

Tony Wells, Rural Health Workforce Australia

At the end of the day, primary care and primary health care are all about the patient.

We need to ensure people get quality, first-level health care regardless of where they live.

We need to support the role GPs play in the health care team, promote multi-disciplinary team-based care (there are some great examples in remote clinics) and encourage greater ‘health literacy’ so patients with chronic disease get the information they need to manage their condition.

And we need to recognise the role that health professionals like physiotherapists and dieticians can play in this process.

Isn’t this what a caring health system should be about?

The shortage and uneven distribution of GPs and other health professionals contribute to Australia having a higher hospitalisation rate than other advanced countries.

At least 731,000 hospital admissions in 2007-08 were potentially preventable if timely and adequate non-hospital care had been provided.

That’s a lot of avoidable pain, suffering and cost to the community.

***

Professor Alan Rosen, Secretary, Comprehensive Area Service Psychiatrists’ Network; Clinical Associate Professor, Brain & Mind Research Institute, University of Sydney; Professorial Fellow, School of Public  Health, University of Wollongong

The Feds too are confused about these terms, just as  they are about the difference between primary health and community  health. They confound these terms and often use them  interchangeably in their communiques.

It is ominous that Primary care centres will now be called “Medicare-locals”. Like the hospital-centred overbalancing of the bulk  of Kevin Rudd’s reforms, the medicare-local moniker and imagery encourages a shift away from interdisciplinary primary health (with  psycho-socio-cultural interventions to deal with social determinants  of disease), overbalancing towards a narrower focus on primary care,  dominated by doctoring and biomedical solutions and procedures. The exclusion of community mental health services for more severe  psychiatric disorders from consistent co-location with primary health centres further reinforces and signals this eclipsing of the psycho-social by the biomedical, rather than a wholistic integrating of both.

****

• Meanwhile if you’ve still an appetite for more reading about primary care, this is a summary of a recent theme issue on the subject in the journal Health Affairs, looking mainly at the state of play in the US.

• And this article by Thomas Aschenbrener, president of Northwest Health Foundation in Oregon, imagines how primary care might look in 2025. Nurse-led practices are the order of the day….

• Another post coming on these issues soon, in the final part of the primary care VS primary health care series….