High-quality primary healthcare: addressing the challenges here and now

Introduction

High-quality primary care has long been recognised as an integral part of achieving comprehensive healthcare for all with reduced mortality and better population health at lower societal cost [1]. In addition to traditional conceptualisations of healthcare quality, high-quality primary care also needs to be continuous, comprehensive, coordinated, first contact accessible and more broadly people- and community-centred [2].

In recent decades significant improvements in global maternal and child health and specific infectious diseases such as HIV and TB have been driven primarily by vertical programmatic efforts. Concurrently, the global burden of disease has been shifting towards longer term chronic conditions with associated care complexity as populations age [3]. In higher income countries a disease-centric view of health care has emerged raising many challenges, including cost, inefficiency and the potential for inequity due to limited supply and geographic access to sub-specialised care. Persisting with this siloed model of healthcare provision risks ever increasing fragmentation of people, their context, illnesses and health undermining primary care comprehensiveness, holistic person-centredness, coordination of care, integrated preventive care and continuity, which when preserved has been shown to lead to longer and healthier life [4]. Low and middle income countries face a triple burden of disease as high rates of injuries and communicable disease persist, with many primary healthcare systems ill equipped to manage this. In some settings the quality of healthcare is so poor that people may be better served by avoiding healthcare entirely [5].

Despite recent advances in measurement and innovative models of primary healthcare delivery, a significant knowledge and implementation gap remains in how national health systems globally can consistently achieve high-quality in this unique context, particularly as the dominant influences on national quality and patient safety standards and in quality improvement initiatives have in many instances come from secondary and tertiary care settings [6].

While the provision and adequate resourcing of primary healthcare is necessary, there is an imperative to maximise the impact of this care by addressing some of the wider challenges to realising high-quality primary healthcare for all patients everywhere.

As a community and focal point for global quality and patient safety improvement, the International Society for Quality in Healthcare (ISQua) hosted a pre-conference workshop at its 40^th international conference in Istanbul to explore high-quality primary healthcare globally. Through examples of successful implementation approaches shared at this workshop we explore how learning from community engagement in Ghana, integrating quality systems in Thailand, tackling inequity in the United States and building quality improvement capacity in Scotland can help nations to meet some of these big challenges here and now.

Community engagement

In Ghana, the Community Health Planning and Services (CHPS) program is a national health policy and set of primary care standards designed to deliver high-quality primary care through community engagement. Community health volunteers are selected by the community, often at durbars and local community gatherings chaired by the chief. These volunteers are then trained to provide basic health education, identify children for immunisation, help to provide counselling on family planning and link community members to community health officers and nurses to provide treatment for common conditions such as malaria and diarrhoeal illnesses. For more serious illness, these volunteers readily refer members of the community to the community health officers for timely assessment and treatment. In addition to managing a broader range of common conditions, community health officers also provide immunisation and antenatal care and provide education on sexually transmitted infections and HIV, while also fulfilling a local health reporting role to sub-district health management teams.

CHPS is community-centred, coordinated, readily accessible and continuous. Its success is rooted in shared culture and community ownership of health. Quality and safety of care is accordingly the responsibility of all: volunteers, officers and members of the community. Alongside this ethos, standards define reporting and supervision arrangements from each community, through sub-district and district heath management teams, to the Ministry of Health [7]. This model of primary care provision leverages kinship as a driver of quality and represents co-production of healthcare service within a specified structure, or what has been termed Quality 3.0 [8].

Integration of quality systems

Thailand has been at the forefront of developing primary care to achieve universal health coverage, with over 99% of the population now able to access healthcare. This achievement stems from over 40 years of strategic development in health infrastructure, human resources, quality of care mechanisms and decentralization of health services, rooted in the principles of equity and accessibility. With broad national reach and significant expertise in quality and its improvement, the Healthcare Accreditation Institute (HAI) is a publicly funded body tasked with establishing the standards for quality and assuring quality across the hospital system in Thailand. In recent years, HAI’s role has grown to encompass a more integrated approach that includes development and implementation of primary care standards and a network-based accreditation model [9].

Primary care standards developed by HAI focus on three key components: purpose (organizational goals), process (primary care services, public health services, and support functions), and performance results, which aim to foster improvement of services, personnel, and systems. These standards undergo context specific testing in voluntary areas before application to ensure usability. The Network accreditation model, known as District Health System Accreditation integrates the community’s district hospitals and Sub-District Health Promoting Hospitals (SHPH) using clinical pathways to create cohesive networks in which primary care is provided. The majority of community hospitals have achieved HA hospital accreditation, with increasing numbers of district health networks certified. For urban primary care, HAI has continuously refined standards over the past decade, emphasising alignment with local governance and fostering self-management capacity.

By fostering greater continuity and coordination of care quality, this approach lays the groundwork for further expansion of comprehensive primary care into rural areas. Future developments aim to shift from organisation-specific standards to a comprehensive, system-wide focus on the patient journey, in the pursuit of seamless care across traditional care boundaries within a larger geographic setting.

Tackling inequity

Societal inequity is a huge challenge to achieving high-quality primary care in the United States resulting in well-documented disparities in both access and outcomes. The Federally Qualified Health Centre (FQHC) model has emerged as a mechanism for the provision of primary care to medically underserved communities, defined as those with financial hardship, low-income populations and specific populations such as migrant workers, the homeless, and residents of public housing. Services are provided based on a sliding scale fee linked to ability to pay reflecting the key principle that nobody is turned away.

Approximately 1400 centres with >300 000 staff provide care to over 30 million people across every US state and territory. A key tenet of this model is that it is rooted in the community it serves, with at least 51% of governing board members representing patients served by the centre as drawn from its population demographics. Non-patient board members must also be otherwise representative of the community and have appropriate legal, financial, community affairs, local government, labour or social services expertise [10].

As a federally funded system, FQHC centres are bound by quality standards and reporting of key metrics. These standards mandate quality improvement with metrics demonstrating improvements in immunisation rates, cancer screening uptake and management of chronic disease in recent years. Underscoring the commitment to equitable primary care, these metrics must be disaggregated by race/ethnicity, age, gender, language, insurance status, diagnosis and service type. Identified disparities trigger quality improvement activities that are part of the FQHC quality management system. Through these requirements, standards and guidance from the US Preventive Services Taskforce, FQHCs address primary care quality problems that stem from inequities that are contextually relevant in their communities.

Building capacity

The National Health Service (NHS) in Scotland has developed substantial infrastructure for building quality and safety improvement capacity within primary care. Designed and delivered by NHS Education for Scotland, practical training programmes in quality improvement and patient safety are targeted at multiple systems levels within primary care. Education is tailored for different groups, from General Practitioners (GPs) in training, to GP multidisciplinary teams operating at practice level and for regional clusters of GPs working within a defined area on wider systems problems. Training is delivered both online and in-person and supported by an extensive online library of general practice specific tools and resources. Primary care practitioners can also develop further leadership skills in quality improvement and patient safety alongside peers from secondary and tertiary care through programmes such as the Scottish Quality and Patient Safety Fellowship.

Human factors principles are deeply embedded within QI and patient safety education in Scotland. Systems understanding and engineering principles, drawn from models such as the Systems Engineering Initiative for Patient Safety (SEIPS), inform the development of tools and resources for use in general practice [11]. These principles support more effective improvement work in the complex, dynamic and often unpredictable context of primary care. One commonly applied tool is the enhanced significant event analysis, where a structured systems-based approach is used to maximise learning from patient safety incidents, especially where there is an associated emotional impact on staff [12]. Through the integration of human factors into QI and patient safety education, a deeper capacity for better design can be realised to integrate patient safety into QI programs in primary care.

Conclusion

In the age of the sustainable development goals, universal healthcare and shifting global burdens of disease, primary healthcare must play a central role in realising better health for all. High-quality primary care requires deliberate design and action for maximum population benefit. In addition to learning from quality and quality improvement approaches that have been employed in secondary care settings, it is vital that we share, build upon, implement and monitor primary care specific strategies that engage communities, integrate quality systems, tackle inequity and build primary healthcare quality improvement workforce capacity. In addressing these challenges and opportunities across the world, and in all healthcare systems we must connect to share knowledge, promote learning and translate evidence into practice such that the goal of high-quality primary healthcare for all may be achieved.

Author contributions

John Brennan and Bruce Agins were involved in conceptualisation, writing original draft, review and editing, all other authors were involved in writing - review and editing.

Conflicts of interest

None declared.

Funding

None declared.

Data availability

There are no new data associated with this article.