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Primary care in the health care system

Lecture: Phase 2: Society and Health, University of New South Wales

Michael Tam

on 23 August 2013

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Transcript of Primary care in the health care system

Definition of primary care?
Prof Barbara Starfield, MD MPH
renowned researcher and author
advocate for primary health care worldwide
John Hopkins University
Secondary care
Medical specialists, some allied health professionals
Usually consultative and short-term in nature
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
Secondary and tertiary care are distinguished by their duration as well as by the relative uncommonness of problems that justify them.
Starfield B. Is primary care essential?
Lancet 1994; 344: 1129-33
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.”
Stange KC, Ferrer RL. The paradox of primary care [editorial]. Ann Fam Med 2009; 7: 293-9
learning objectives
Define "primary care"
Describe the types of presentations in general practice
Define "primary health care" as a health care system and explore alternatives
Describe and explain the impact of primary care on outcomes, costs and equity
Starfield B, Is primary care essential?
Lancet 1994; 344: 1129-1133
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 and promoting the health
of people in communities
Provision of
1st contact
, person-focussed, ongoing longitudinal care
Meets the health-related needs of people
Referring only those too uncommon to maintain competence
Co-ordinates care
when peopled receive services at other levels of care
Tertiary care
1 patient admitted to a teaching hospital
(tertiary care)
10 patients present to hospital
(secondary care)
250 patients visit their GP
(primary care)
500 patients experience illness at home
1000 adults - monthly illness prevalence
Adapted from: Green LA, Fryer GE, Yawn BP, et al. The ecology of medical care revisited. N Engl J Med 2001; 344:2021-2025
General practice: a snapshot
In 2009/10:
124 million Medicare services (40.3%)
32.3% of Medicare costs
~ 6% of total health expenditure
Significant influence on total expenditure on drugs, specialist care and hospitalisation.
What problems do GPs see?

Check-up - all

Upper respiratory tract infection


Arthritis - all

Diabetes - all


Lipid disorders

Back complaint

Oesophageal disease









Problem N/100 encounters
Who else apart
from GPs?
Community services
Allied health services
Home and community care
Indigenous health services
Primary health care
Primary care applied to a
community / population level
As a population strategy, it requires the commitment of governments to develop a
population-oriented set
primary care services
in the
context of other levels & types of services
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."
Towards a National Primary Health Care Strategy: A discussion paper from the Australian Government. 2008
why is primary care important
Better health outcomes

Lower cost

Greater health equity


Outcomes: between countries
Phillips R, Starfield B. Why does a US primary care workforce crisis matter? American Family Physician 2003; 68(8): 1494-150
Outcomes: within a country (US)
Shi L, Starfield B, Kennedy B, Kawachi I. Income inequality, primary care and health indicators. Journal of Family Practice 1999; 48 (4): 275-284
Life expectancy = UK
Life expectancy = Mexico
Outcomes: cutting primary care
Simms C, Rowson M. Reassessment of health effects of the Indonesian economic crisis: donors versus the data.
Lancet 2003; 361: 1383-5
Costs: between countries
Costs: primary care on health utilisation
Phillips R, Starfield B. Why does a US primary care workforce crisis matter? American Family Physician 2003; 68(8): 1494-150
Kravet SJ, Shore AD, Miller R, et al. Health care utilization and the proportion of primary care physicians. Am J Med. 2008; 121: 142-8
Gapminder graph
Inequality: between countries
Collison D, Dey C, Hannah G, Stevenson L. Income inequality and child mortality in wealthy nations. Journal of Public Health 2007; 29(2): 114-7
Inequality: impacts in the US
Adapted from: Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004; 291(10): 1238-45
Inequality: impacts in the US
Galea S, Tracy M, Hoggatty KJ, et al. Estimated deaths attributable to social factors in the United States. Am J Public Health 2011; 101: 1456-65
Deaths attributed to social factors
Low education
Racial segregation
Low social support
Individual-level poverty
Income inequality
Area-level poverty
245 000
176 000
162 000
133 000
119 000
39 000
Life expectancy?
Effective health care

Efficient health care

Reduced health disparity
reduced all cause mortality
reduced cardiovascular mortality
less hospital presentations and admissions
better preventive care
fewer investigations
less medication use
higher patient satisfaction
greater access to care
care appropriate to health needs
Benefits of good primary care
“Primary care as a hub of coordination (Figure 3.5)” in The world health report 2008 – primary health care (now more than ever). World Health Organisation: 2008. p. 55
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