Home > Publications > Full text online > Primary care: a new direction

PART 1 Background - the need for change

What is primary care?

For the purposes of the Health Strategy, primary care is defined as follows:

Primary care is an approach to care that includes a range of services designed to keep people well, from promotion of health and screening for disease to assessment, diagnosis, treatment and rehabilitation as well as personal social services. The services provide first-level contact that is fully accessible by self-referral and have a strong emphasis on working with communities and individuals to improve their health and social well-being.

This means dealing with health problems at the lowest level of complexity. Primary care is the first point of contact that people have with the health and personal social services and should be available to all people regardless of who they are, where they live, what their income is or what health and social problems they may have. Primary care is the part of the system that ensures that services are co-ordinated and integrated across the boundaries of health and personal social care to the benefit of the consumer in terms of better quality, better outcomes, better cost-effectiveness and better health status. The Declaration of Alma Ata in 1978 was an important milestone in the promotion of world health and outlined the concept of primary health care.

The term 'primary care' is often used synonymously with 'general practice'. While general practice is a key element, it is broader than general practice alone. It encompasses a wide range of health and personal social services delivered by a variety of professions. Primary care providers can make a significant difference not just in treating illness, but also in supporting people to care for themselves and their families, improving wellness, preventing illness and supporting those with long-term problems, from a health and social well-being perspective.

Primary care includes the range of services that are currently provided by general practitioners (GPs), public health nurses, general nurses, social workers, practice nurses, midwives, community mental health nurses, dieticians, dentists, community welfare officers, physiotherapists, occupational therapists, home helps, health care assistants (see Appendix 1), speech and language therapists, chiropodists, community pharmacists, psychologists and others. The current primary care system is delivered by a combination of these disciplines, very often working in isolation, either as private practitioners or as direct employees of the public health system. GPs are independent contractors while most other services are provided by employees of health boards and voluntary organisations. An outline of the national policy context and a more detailed description of current service provision is presented in Appendix 1.

The need for change

Better health for everyone is the first national goal of the Health Strategy 2001. This requires a mobilisation of effort across various sectors with an influencing role on the health status of the Irish population. The reform and development of health and personal social services in Ireland planned over the lifetime of the new Health Strategy aims to deliver improvements in the personal experiences of the many thousands of individuals who are availing of services every day. The ease of access to services, the quality, responsiveness and timeliness of the treatment and care received and the degree to which individuals are supported in leading healthier and more independent lives in their own communities are fundamental indicators for people of how well their needs are being served.

The development of a high-performing health system will require, among many other things, that the overall volume and range of health and personal social services available be greatly expanded over the coming years. In seeking to achieve this, investment and effort needs to be focused on the parts of the service that are best placed to provide maximum return, to grow to serve unmet need and to deliver the kind of person-centred, holistic and locally accessible range of services that are required if the Health Strategy is to make a real difference.

The development of primary care offers great potential to achieve the growth and development in service provision required. The existing strengths of primary care services in Ireland provide a very firm foundation on which to base the level of expansion and development that is needed. These strengths are evident, for example, in the satisfaction that has been expressed with GP services during the consultation process for the Health Strategy. Primary care services are available in their various forms in every part of the country. Their locally accessible and personal nature facilitates close ongoing relationships between provider and patient.

However, the current system of primary care has many inadequacies which must be addressed. It is fragmented from the user perspective and is difficult to access out-of-hours. The current system also places emphasis on diagnosis and treatment while having limited capacity for health promotion, prevention of illness and rehabilitation. The limited impact of current approaches to prevention particularly need to be addressed if the improved health status targets of the Strategy are to be met. There is a scarcity of many key professional groups which results in secondary care* having to provide a number of services that are more appropriate to primary care. In the future, additional challenges will arise from increases in the population of elderly and high-dependency groups. This will add to the pressures on the secondary care system. Strong public demand exists for the development of locally responsive services to meet these needs.

* Secondary care refers to specialist services with may be either community- or hospital-based.

Principal inadequacies in current system of primary care

Poorly developed primary care infrastructure and capacity
Current system fragmented from users perspective
Limited opportunities for user participation in service planning and delivery
Emphasis on diagnosis and treatment with weak capacity for prevention and rehabilitation
Potential to reduce pressure on secondary care not fully realised
Secondary care providing many services which are more appropriate to primary care
Current system oriented around needs of providers rather than those of users
Out-of-hours services underdeveloped
Limited availability of many professional groups
Professional isolation
Limited teamworking
Communication between professionals and sectors inadequate
Lack of quality assurance framework
Limited information from primary care for planning, development and evaluation

In considering the options for developing and enhancing the services, a four-part analysis was undertaken.

The analysis included an examination of primary care as it currently stands in terms of strengths, weaknesses, opportunities and threats; the identification of the main messages from the consultation process undertaken as part of the preparation of the Health Strategy; a review of the international evidence base for key aspects of primary care; and consideration of systems of primary care in other countries. The details of each of the four components are set out in Appendix 2.

Key conclusions that can be drawn from this analysis are as follows:

Developments in primary care should build upon and add to the very significant strengths of the system that currently exist in Ireland. Same-day access to many primary care professionals and co-operative working for GPs in some areas on an out-of-hours basis, are examples of these strengths
The commitment of individual professionals and their professional organisations has compensated for the absence of a well-developed infrastructure for primary care
The skills and commitment of individual professionals are not employed as effectively as they could be. GPs, for example, can be isolated from many other community services. Communication and work-sharing with other primary care professionals is not always readily facilitated or supported
Primary care infrastructure is poorly developed and the services are fragmented, with limited teamwork and availability of certain professional groups
Liaison between primary and secondary care is often poor and many services provided in hospitals could be provided more appropriately in primary care
Primary care out-of-hour services are underdeveloped
Key concerns to emerge from the consultation process for the Health Strategy relate to the need for an improvement in local access and availability of care out-of-hours; and the need for improved integration of services, so as to create a seamless, people-centred service in the community
Many countries are now developing primary care services as the cornerstone around which their health services are built. These countries have prepared national strategies that have highlighted the importance of a team-based approach to primary care
Common themes that have emerged from international strategies include: the key role of inter-disciplinary teamworking; the importance of preventive services; the need for improved information; and the importance of patient enrolment
There is evidence in the published health literature of the success of primary care in providing continuity of care and in playing a crucial gatekeeper role to secondary services
Teamworking has been shown to provide a more responsive service to patients who benefit when health professionals work together with an appropriate skill mix.
The analysis indicates that primary care, planned and organised on a 24-hour basis, has the potential to lessen the current reliance on specialist services and the hospital system, particularly accident and emergency and out-patient services.

Conclusion

All but the most complex and acute health care needs of individuals, families and groups may be effectively met within the primary care setting. The management of that wide range of care in this setting represents the most appropriate, effective and user-friendly approach to the organisation of service delivery. The development of primary care services, so that they become the cornerstone of care and preventive services for communities across the country, is consistent with best international practice. This document proposes a model through which the increasing need for health and personal social services can be significantly addressed through the orderly development of primary care based services.

The weaknesses of the current system, the views expressed during the consultation with the public, and the international evidence point to the need for change in the way primary care is planned, organised and delivered in Ireland. The principal change required is a shift in the balance from secondary specialist care to primary generalist care. This will need major investment in the development of an appropriate infrastructure for primary care.

The proposals outlined aim to develop the capacity and infrastructure of primary care so that it:

is easy to access and understand
is available when needed
helps people to stay healthy
provides appropriate care in the appropriate setting
improves the health of the local community and the overall population
enables people to take control of and responsibility for their health co-ordinates on-going care for individuals and families
contributes to reduction in health inequalities
responds to the needs of individuals and families when problems or acute needs are experienced.

It is important to note that the new model does not affect in any way the current status of GPs or the professional-patient relationship, with members of the primary care team.