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Definition of primary care

  • As a level of care:
    • 1st level of care that people have contact with the health system
    • level at which most health problems are identified, managed or referred
  • Focus on protecting & promoting the health of people in communities
  • Needs access and timeliness, triaging
  • provision of 1st contact, person- focussed ongoing longitudinal care
  • meets the health-related needs of people
  • referring only those too uncommon to maintain competence
    • there has to be a reason that you think another health practitioner has better knowledge than you do
  • co-ordinates care when people receive services at other levels of care

Distinctive features of primary care

  • Effectiveness and safety are not just technical matters
    • effectiveness of drug treatment doesn't just depend on the pharmaceutical - it also depends on whether people actually take the drug, how it's delivered etc
    • you need to understand the person's greater social context
  • Understanding people: person-centred care
  • Comprehensive and integrated responses
    • including dealing with multiple conditions
  • Continuity of care
  • A regular and trusted provider as entry point


  • Primary care is not focussed on just diseases, but on helping people stay functional and happy overall

What is not primary care?

  • Secondary care
    • Medical specialists, some allied health professionals
    • Usually consultative and short-term in nature
  • Tertiary care
    • Complex care in hospitals, multiple providers
    • Care for patients with disorders that are so unusual in the population that primary-care physicians could not be expected to see them frequently enough to maintain competence in dealing with them
  • 1/100 or 1/200 people are sent to hospital
  • For one person admitted to tertiary care, there are 10 patients who present to secondary care.
  • For this 10, there are about 250 who present to primary care (sensitivity and specificity etc on these people are less useful: careful not to overinvestigate)
  • 500 patients experience illness at home
  • 250 are "well" with disease

Primary care physicians - RACGP

  • In Australia the mainstay of primary care is provided by GPs
  • Defining characteristics:
    • Person centredness
    • Continuity of care
    • Leadership, advocacy and equity
    • Comprehensiveness
    • Diagnostic and therapeutic skill
    • Coordination and clinical teamwork
    • Whole person care
    • Continuing evolution of the discipline
    • Professional, clinical and ethical standards
    • Continuing quality improvement

General practice: a snapshot

  • In 2009/10:
    • 124 million (40.3%) Medicare services
    • GP = 32.3% of Medicare costs
    • GP ~ 6% of total health expenditure In 2005:

**GPs have significant influence on total expenditure on drugs (24%), specialist care (8%) & hospitalisation (29%)

What problems GPs see

  1. Hypertension (1/10)
  2. Checkup - all
  3. URTI
  4. Immunisation/vaccination
  5. Arthritis -all
  6. Diabetes - all
  7. Depression
  8. Lipid disorders
  9. Back complaint
  10. Oesophageal disease

Primary health care

  • General practice
    • Largely private small/medium enterprises
    • (Commonwealth DoHA)
  • Community services/allied health services
    • State funded & run
    • private
  • Home and Community Care
    • Commonwealth grants & some State Indigenous Health Services
    • Commonwealth DoHA – direct grant & MBS
  • Pharmacy
    • Largely private small/medium enterprises
    • (Commonwealth DoHA)
  • Primary care applied on a community / population level
  • As a population strategy, it requires the commitment of governments to develop a population-oriented set of primary care services in the context of other levels & types of services
  • Homework: Declaration of Alma-Ata 1978
  • Strategy, policy, health development
    • “Improvements in primary health care are critical to improvements in the overall health system. In particular, primary health care is vital in turning our health care system more towards keeping people well and participating in life and work, rather than just looking after people when they are sick.

Why is primary care important?

  • Better health outcomes
  • Lower costs
    • Zero sum game
  • Greater equity in health

Outcomes: between countries

  • Better primary care = better health care outcomes
  • Primary care rank is a rank of primary scores. The primary score is derived from the average of scores on 11 features of primary care.
  • The average health care outcome rank is an average of ranks for the following outcome measures: patient satisfaction, expenditures per person, 14 health indicators & medications per person.
  • More primary care physicians/10000 population = higher life expectancy
    • MD is outlier because of Johns Hopkins (hard cases --> more death)

Outcomes: cutting primary care

  • Primary care and infant mortality rates in Indonesia
  • Indonesians lost primary care and maintained hospital expenditure --> 14% higher infant mortality.

Costs: between countries

  • The better your primary care score, the less per capita health care expenditure you have

Costs: primary care on health utilisation

  • The more doctors you have in primary care, the less hospital admissions
  • Also, the more doctors you have in primary care, the less surgeries happen
  • The more income inequality in an OECD country, the higher the rate of infant mortality - it's NOT correlated to overall GDP.

Life expectancy

  • USA is 36th rank in life expectancy. A lot of other countries have overtaken the USA.

Inequality - impacts in the US

  • Leading causes of death
  • Actual causes of death
  • "actual causes" are attributed to social factors

Deaths attributed to social factors

  • Low education
    • 245 000
  • Racial segregation
    • 176 000
  • Low social support
    • 162 000
  • Individual-level poverty
    • 133 000
  • Income inequality
    • 119 000
  • Area-level poverty
    • 39 000

OECD Health Data 2010

  • U.S. vs Australia (2007)
  • US Australia
  • %GDP 15.7% 8.5% $US/capita $7,285 $3,353 Life expt: 36th 6th

Benefits of good primary care

  • Good access to primary care results in:
    • Effective health care: reduced all- cause mortality, mortality from CV disease, less E.D. admissions & hospitalisation, better preventive care, better detection of cancer
    • Efficient health care: fewer tests, less medication use, higher patient satisfaction
    • Equity: reduced health disparities

Primary care and health: evidence-based summary

  • Countries with strong primary care
    • have lower overall costs
    • generally have healthier populations
  • Within countries
    • Areas with higher primary care physician availability have healthier populations
    • Lower use of hospitals
    • More primary care physician availability reduces the adverse effects of social inequality

The “primary care paradox”

  • "... compared with specialty care or with systems dominated by specialty care, primary care is associated with the following: (1) apparently poorer quality care for individual diseases, yet (2) similar functional health status at lower cost for people with chronic disease, and (3) better quality, better health, greater equity, and lower cost for whole people and populations.”
  • WHY?
    • Medical specialists occupy only one portion of the health system
    • GPs provide greater access to care, hit more of the population etc