The future shape of primary care

There is no shortage of international policy documents outlining the importance of primary care. But does the reality match up to the rhetoric? This is answered in part in a study by Kringos et al.¹ They describe primary care in 31 European countries in terms of investment in primary care, governance, workforce development, access, services delivered, continuity, coordination, comprehensiveness, and GPs’ income.

One fundamental, if not surprising observation is that primary care is highly variable. This starts from defining who provides primary care, to whether ‘GP’ means the same thing in different countries, whether GPs work single-handedly or collaborate with others in multidisciplinary teams, whether they have a gatekeeping role, whether they have a registered list and the range of services that are provided, to working conditions and income. Using a wide range of indicators on the different dimensions, Kringos and colleagues developed a measure of ‘strength of primary care’, according to which countries such as the UK, Denmark, and Netherlands rank top, while others such as Austria, Cyprus, Greece, Hungary, and Ireland score poorly on care structures considered key for strong primary care. The study provides a great deal of detail to add to previous surveys documenting wide variation between primary care in different countries.²

CHALLENGES FOR PRIMARY CARE

In a separate article, the same authors looked at the relationship between strength of primary care countries and the outcomes and the cost of health care provided.³ They found that countries with strong primary care systems had better health outcomes but, contrary to received wisdom,^4,5 these countries had more expensive healthcare systems relative to national income. However the article suggests no room for complacency in terms of thinking that primary care is necessarily cheaper than specialist care. Nor can we be complacent about primary care producing better health outcomes: Vedsted and Olesen⁶ found that countries in which GPs were gatekeepers to specialist care had lower survival for cancer, which suggested that gatekeeping might have ‘unexpected serious side effects’. Countries such as France, which are rated medium in terms of primary care, are among the top performers in relation to health outcomes that can be attributed to health care.⁷

So where are we then? There is widespread variation in the way primary care is conceptualised and implemented, and some uncertainties about the costs and effectiveness of primary care. What is clear is that the changing burden of disease vis-à-vis ageing populations requires a different approach to service delivery and components such as continuity and care coordination that are core dimensions of primary care, which have been shown to be effective (to a degree) to meet the needs of those with complex conditions.^8,9 How should we then expect primary care to develop in the future? We address this from two perspectives: how should primary care be organised? And how should it be financed?

FUTURE ORGANISATION OF PRIMARY CARE

There is increasing recognition that primary care should be organised to take responsibility for whole populations of patients. In countries with registered populations GPs take responsibility for screening programmes and increasingly for a wide range of chronic disease management programmes. However, one of the key objectives in extending GPs’ population responsibilities in future is to improve the integration of care which is a major priority with our increasingly aged and multimorbid patients. To do this general practice needs to change. GPs increasingly need access to the skills of a multidisciplinary team and to facilities for investigation and treatment. This is at odds with the organisation of general practice in many countries where GPs are self-employed, often working single-handed or in small groups. Recent work describes a number of models which are emerging in the UK and other countries that seek to provide the benefits of organisational scale while preserving the local nature of general practice,^10,11 suggesting design principles for clinical care and organisation of general practice that will be needed to meet the needs of patients in future.¹⁰

FUTURE FUNDING OF PRIMARY CARE

We also need new models of funding primary care to enable provision of better integrated care. Increasingly, there are moves to try to promote integration of care through so called ‘bundled payment systems’ which may include payments being made to more than one provider (that is, primary and secondary care) to cover whole episodes of illness, or for implementing care pathways or disease management programmes. Such schemes are now evident in the Netherlands.¹² These schemes recognise that payment systems which encourage multiple providers and give them different incentives are unlikely to provide well coordinated care. Pay-for-performance is also increasingly used in primary care and has spread from the UK to Germany, France, Estonia, Hungary, and Sweden despite limited evidence of its benefits unless used as part of other quality improvement initiatives.¹³ Pay-for-performance schemes also have a problem that they tend to prioritise the management of single conditions over integrated care.

A major recent innovation in funding is the potential for primary care to use its population responsibility to take on wider financial responsibility for patients. The first example is in the UK where groups of GPs (clinical commissioning groups) now have budgetary responsibility for the majority of the healthcare budget to their patients including hospital and specialist care. The second example is in the US where the concept of ‘accountable care organisations’ gives budgetary responsibility for defined populations to providers of health care, although in the US this is more likely to be a combination of generalists and specialists rather than primary care physicians having lead responsibility.

An anomaly of the UK’s current healthcare reform is that the CCGs are responsible for purchasing specialist care but do not have responsibility for primary care. It seems clear that they cannot manage a population budget without taking an interest in both, and early indications are that they are doing exactly that with, for example, contracts that involve specialist, primary, and community care.¹⁴ Currently neither hospital nor general practice payment systems in the UK encourage integrated care, and both need to change to do so.

THE NEED FOR REFORM

Primary care in many countries is unrecognisable from 20 years ago. Countries are bound to continue to reform their healthcare systems to deal with the new challenges of ageing populations, and therefore changes to both the organisation and financing of primary care are inevitable. GPs have proved to be both adaptable and entrepreneurial over many years. They will need to show continued ability to adapt to a changing environment.

Provenance

Commissioned; not externally peer reviewed.

Competing interests

The authors have declared no competing interests.