Primary Care in the Twenty-First Century

An International Perspective

Geoff Meads

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315358239
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Quality is at the heart of the government's strategy for NHS development, and which is to be delivered through clinical governance. This book explores accreditation through practical case studies and research findings, and outlines how it can assure the quality of care. Systems of accreditation for measuring and improving quality are described, and show how they can be used easily and effectively to meet the challenges of the new NHS. It is clear, concise and relevant to all the current changes in healthcare provision. All those responsible for delivering a service based on clinical and cost effectiveness will find it essential reading. 'In the United Kingdom primary health care is based almost wholly on general practice. From April 1999 all general practices will belong to primary care groups. Questions of quality and accountability will be high on their agenda as part of the new arrangements for clinical governance. This book on accreditation in primary care is therefore most timely.' Sir Donald Irvine, President, General Medical Council, in the Introduction.

Chapter 1

International approach

Terms of reference

Thirty-three countries and 34 months. Democracies only; with the possible exception of Cuba, given its sustained global influence over the organisation of primary care. Dr Che Guevara and President Fidel Castro as the founding fathers of Health for All policies: if they shaped international developments during the second half of the twentieth century who are the formative forces for the first half of the present one? Such a fundamental question needs a clear and cogent analysis: robust terms of reference are required.

So, back to our defining agenda. Only countries with major health policy reforms over the past decade, and preferably since 1997 when the New Labour Government came into power in the United Kingdom. Even better if the changes are post-millennium and parallel Prime Minister Tony Blair’s mantra of ‘Modernisation’ for a ‘New NHS’. Fortunately the organisational developments of many countries more or less do.

And, for the purposes of comparability, small countries are mostly ruled out. Take ten million as the arbitrary minimum population. But again, on the advice of two directors of the World Health Organization (WHO), there need to be exceptions to the general rule. Some countries are in effect experimental laboratories for modernising and primary care-based health policies - Uganda, Kyrgyzstan and Georgia for instance are, we learnt, sometimes seen informally by global policy makers as three such action research sites. Others ape the complexity of political process and decision making found in larger nation states; and worldwide devolutionary pressures mean, perhaps, that some provinces might even be considered. Ontario (Canada), Oaxaco (Mexico), New South Wales (Australia), Lara (Venezuela) and Northern Ireland, for example, come to mind; but probably not in their own right. Ultimately they are illustrations of the new extended limits of national health policies for local resource management. But, of course, small country success stories should at least be mentioned, where they fit the criteria. Costa Rica and New Zealand definitely, Singapore too, and Greece simply because it seems to be experimenting with the introduction of every health policy reform yet invented; and simultaneously.

So, back to the criteria again. We are looking to make sense of primary care in the twenty-first century. Our perspective is global and our lens alights on developments in countries with novel organisational formations in primary care. These developments have broadly common characteristics. They are partnership based and public health oriented. Their new collaborative approaches to the wider local control of health services and resources require new forms of governance and regulation. Usually these primary care organisations are not only interprofessional in their practice but intersectoral in their management. Non-governmental public action is a critical component. Communities play a larger part in the executive functions than previously, but in very different ways in very different places: a spectrum stretching from commercial to charitable representation. And, on all fronts, these organisational developments are more open to international influences, through globalisation, than ever before. We live, as the Chinese say, in interesting times and, of course, China itself as the world’s largest country, its ‘Middle Kingdom’, must be included.

Making sense of such times, through defining their direction of travel, is our task in this book. Its preparation has itself involved much travel: 75 flights in one year alone, 280 000 kilometres in all. Along the way more than 200 interviews and 50 visits to local primary care organisations: each one identified by a ‘lead’ national policy maker as an exemplar of future practice developments. In total, an exhilarating experience and an educational one, leading to numerous follow-up exchanges, both personal and academic, and a plethora of joint articles, shared ideas and curricula, and proposals for further research collaborations.* The theme has been ‘transferable learning’, with common policy principles the framework for adaptation if not adoption of one site’s programmes by its prospective partners elsewhere.¹

As terms of reference, all the above parameters seem to have come together to produce a successful product. A one-year project became a proposed seven-year-long research unit (to 2008). For the author, one fellowship led to another, and NHS grant funding throughout 2002-05 was annually renewed with ‘strong’ ratings from reviewers. Published articles total more than 20 and this is already the second book, augmenting a series of chapters in other volumes, with some even attracting overseas translations into other languages.^2,3,4,5 There seems to be a thirst for new knowledge through the kinds of multinational exchanges and communications now possible, while just within policy circles of the UK the emphasis on ‘joined-up government’ has meant briefings and seminars not only at the Strategy Unit of the Ministry of Health but also in the Home Office, the Treasury and, inevitably, the Cabinet Office itself.

As time has passed so such inputs have increasingly, and not infrequently, been requested elsewhere: for example, from the Midland Health Services Executive in Eire; from the major national health insurance corporation in Mexico (IMSS); from the global organisation for the promotion of community-based healthcare education at its 2003 and 2005 annual conferences in Australia and Vietnam (Network-TUFH); from the Inter-Americas Social Security Association in the Dominican Republic; and finally, from the individuals at WHO (Geneva) itself. The level of demand corresponds to the level of dilemma about the future of primary care and its organisation. In terms of growth, the twentieth century belonged essentially to family medicine and its practice. The twenty-first century clearly does not. In the 1990s in England, it was still quite possible for a leading British professional commentator to write, with minimal challenge, that primary care and general practice were synonymous.⁶ The name of the service was also that of the profession, the surgery and the vocational training course. Ten years later it was all change. In just one decade, official documents in the UK relegated the general practitioner (GP) to seventh in the pecking order for direct patient access: behind the triage nurse and community pharmacist, walk-in and healthy living centres, and, of course, the online information and telephone advice services of NHS Direct.⁷ Moreover, this list does not include, because it pre-dates it, the subsequent drive for more self-managed care, backed up by better educational inputs and preventive measures (e.g. on diet, exercise, birth control) from non-NHS agencies.

As the service profile of primary care diversified so its structures and processes have had to change. It is now, by definition, a complex organisation. The simple forms of hierarchic bureaucracy or peer-based partnerships are inadequate, seem to be rapidly passing away and can no longer apply to future developments. At least not as the main organisational vehicles, unlike in the past. Historic strengths should endure, be protected even, but conservatism clearly has its constraints in terms of understanding the future agencies of and for primary care: in terms of their accountabilities, management, operational mechanisms, investment profiles and human resources; and indeed even their ownership. Constructive scenario planning rather than single strategies is needed to take primary care forward, given its new range of different constituents. The international overview provides a rich resource for mapping the alternative routes to 2100. If it is true that primary care must always be locally negotiated, it is also now the case that its future depends as much on international policy and practice influences as it ever did in the past on professional self-determination. If this is the conclusion reached by researchers in such countries as Zambia,⁸ Colombia and Mozambique,⁹ how much more applicable may it be to the larger, more economically developed and therefore more interdependent States of Western Europe and North America?

The cast list

The 24 countries that have been the subject of specific studies can be divided into four groups. Together they supply most of the material for this book. Not enough clearly, but rather more than some previous texts, which have asserted global ‘truths’ on the basis of evidence derived from as few as four to six countries.^10,11 Our research framework, in geographic terms, does at least cover all the main continents, although North Africa, the Middle East and the Indian subcontinent are conspicuous by their absence, except as literature references. This omission arises largely from the democratic deficit of recent ‘modernising’ reforms in many of the States of these regions, plus a shortfall in reliable research. Our framework, too, also covers the six discernible models of mainstream primary care organisation that we define and explain in Chapter 2, and then illustrate in detail in the narrative of the rest of this book. Based on the terms of reference set out above, the research framework facilitated our deliberations as we arrived at the following focus for our fieldwork.

The first cluster of countries identified for study were those which scored on each of the five criteria or dimensions of modernisation we identified at the outset, through our meetings with NHS policy makers and our reviews of their principal academic sources in terms of policy theorists and commentators.^12,13 Accordingly, in each national health system there was first a contemporary reform process under way promoting a form of local resource management in primary care. This process also included, second, new collaborations across the public and independent sectors, and third, attempts at more significant community participation. In every setting, the emergent organisations have been subject to, fourth, new forms of regulation as governments seek to exercise effectively their national stewardship roles in public health. And fifth and finally, in all of the following 12 countries we found examples, from our literature searches and documentary reviews, of innovations in the area of interprofessional learning and development. Several of these have now been published.¹⁴

Together these five criteria represent the dimensions of a partnership-based health system founded on modern primary care organisations. Our first cluster of countries for fieldwork enquiry in 2003-04 comprised:

• Canada
• Chile
• Finland
• Greece
• Japan
• New Zealand
• Peru
• Philippines
• Portugal
• South Africa
• Thailand
• Uganda

plus, of course, England and, as our pilot site from a preliminary research visit in 2001, Brazil.

In 2003, we returned to Rio de Janeiro for a short follow-up study. By this time the interest in and the financial support for our programme had grown to the extent that we were able to incorporate into our standard fieldwork app...

Table of contents

• Cover
• Title
• Copyright Page
• Contents
• Dedication
• Foreword
• Preface
• 1 International approach
• 2 Future options for family medicine
• 3 The extended general practice
• 4 The managed care enterprise
• 5 The reformed polyclinic
• 6 The district health system
• 7 The community development agency
• 8 The outreach franchise
• 9 Transferable learning
• Index