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What is Primary Care?
“Primary care is 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 practising in the context of family and community.” (Definition of Primary Care. Institute of Medicine, 1974).
There is ample evidence that primary care is more effective in preventing illness and death when compared to health care systems that feature strong secondary care structures. The reasons for this are many, and include the fact that appropriate referrals to secondary care by a primary care doctor familiar with the patient, reduce unnecessary investigations and procedures which may harm patients. This so-called gate-keeping role of family doctors is at the core of primary care services in countries such as the UK, Ireland, and The Netherlands. The first-contact feature of primary care implies that patients do not visit specialists without a recommendation from their primary-care practitioner. In Malta, however, in 2007, more than two-thirds of the 111,688 people attending the emergency department at Mater Dei went there without first consulting their family doctor. Placing the family doctor between the patient and the hospital protects patients by reducing both unnecessary procedures and possible complications.
It is important to realize that the expansion of primary health care services may not always reduce costs because previously unmet needs are identified, and access to services is improved, thus expanding service utilization. However, health care systems with strong primary care elements are associated with a more equitable distribution of health in populations, by removing barriers to health care access for socially deprived people. Money invested in primary care, whether Government funded through practitioner salaries, or through insurance based or co-payment systems, pays dividends in the form of the most cost-effective type of health care. In 1978, the World Health Organisation, at Alma Ata, declared that all member health care systems should be based on a strong primary care element.
Various international studies have shown that the strength of a country’s primary care system is associated with improved population health outcomes for death from all-causes, as well as premature death from major respiratory and cardiovascular diseases. Such systems are also associated with lower costs and better patient satisfaction and self-reported health.
The role of primary care should not be defined in isolation but in relation to the constituents of the health care system. Primary and secondary care, generalist and specialist, all have important roles in the health system. They are not mutually exclusive, but rather necessary ingredients for the system to work effectively and efficiently. However, technological advances, improved education and training, broadening of the roles of the primary care team, different demand patterns due to health transition, and changing social attitudes mean that primary care has a greater role to play than ever before, and resource allocation needs to flow in its favour.
Between 75% and 85% of people in a general population require only primary-care services within a period of a year. The remaining proportion requires referral to secondary care for short-term consultation (perhaps 10-12%) or to a tertiary care specialist for unusual problems (5-10%). In Malta, ninety-five percent of episodes of care start and end in the family doctor’s office. It is frustrating that many of the conditions resulting in preventable hospital admissions are ones which can easily be managed in the community setting. For example, diabetes and cardiovascular disease, which account for a significant proportion of preventable hospital admissions, can be successfully treated by GPs and a primary care team in the community.