By Bernard Merkel (EHFF community member)
Fifty years ago the World Health Organization agreed the Alma Ata Declaration which among other things emphasized the key role of primary care within health system, not least to help achieve equity in health (which means, very crudely put, ensuring that everyone has fair access to healthcare resources) Since then the consensus of people concerned with healthcare services has been to underline the importance of primary care, and the need to strengthen it, and spend more money on it.
We all know the arguments: We must have more primary care to safeguard the health of the general population; primary care is needed to provide the basic services for people – prevention, treatment and care for physical and mental illness; primary care can be provided at relatively low cost and can provide continuity of care for patient , primary care can provide the best entry point into healthcare systems and direct patients to the specialised services they need; primary care can coordinate the input from different services; they can ensure that any necessary follow-up can be undertaken; to avoid unnecessary strains on hospitals and specialist services we must build up our primary care networks .
Although the exact structure and configuration of primary care varies between countries, the basic element is always a system of family physicians or general practitioners (GPs) working in and for local communities. Sometimes they are working as individuals or with one or two other doctors; sometimes they are working in larger clinics with a number of other doctors, and often with other health professionals, frequently nurses, and occasionally pharmacists and other therapists.
One major aspect of the role of primary care doctors in European healthcare systems is to act as a kind of filter: to determine what kind of care was necessary for the patients presenting themselves: do the patients have a condition straightforward enough to be treated in the primary care facility itself, or in fact not requiring any treatment at all? Or do they need to be referred to more specialist services for examination and treatment? In carrying out this role GPs are therefore regarded as important gate-keepers to the healthcare system. This is in principle a sensible idea. GPs should have the knowledge and expertise to ensure that patients are properly assessed and provide any immediate care needed or direct patients to the kind of healthcare service required. Imagine the contrary: a system where patients could decide what kind of condition they had, whether or not it called for any urgent action to be taken and what kind of intervention was needed, and then go straight to see whichever specialist or services they imagined were relevant. Specialists dealing with urgent and serious cases would be swamped by patients with less serious conditions, and the worried well.
However, the model of a tiered system using referrals works well when the system as a whole is functioning efficiently and is adequately resourced. It is much less effective in a situation where the system is under great strain and resources are severely limited – such as is currently the case in the UK and in some other European countries. In these circumstances the primary care referral system can act not as a tool to ensure people get the care they need but rather as an impediment to the delivery of appropriate healthcare. For one thing gaining access to the primary care system in the first place can become more difficult. Take the current situation in England as an example. To get any access to primary care, patients have first to register with a primary care practice. These are in fact decreasing in number as GPs retire or simply leave the NHS. So there are not necessarily practices near where the patient lives, or if there are they may not be accepting new patients. Once registered with a practice, it is not uncommon for patients to have to wait three weeks before managing to get an appointment with a GP. Moreover the GPs can be under such budgetary pressure that they feel it necessary to postpone (or even refuse) referrals to specialist services for diagnostic tests and treatment. The criterion for a referral can thus easily slip in practice from ‘refer a patient when it would seem beneficial to do so’ to ‘refer a patient only when it seems absolutely essential’. This is leading for example to some patients with cancer being diagnosed very late which can reduce the chances of successful treatment. Another example is that of the eye condition, cataracts. Cataracts become very common with age, and so with the ageing populations in Europe, increasing numbers of people are developing them. Fortunately corrective operations are quick, simple and have a very high success rate. However, the more operations there are the higher the healthcare costs. As a result, some UK primary care organisations are not referring patients for cataract surgery as soon as it is evident that the condition has developed, but only once their eyesight has deteriorated to a very significant degree.
The problems besetting traditional primary care services in the UK are having a number of consequences. It is leading many people to use the emergency departments at hospitals as the easiest way of getting quick access to healthcare, so increasing the pressure on them and making it harder for them to focus on serious, urgent cases. It is also leading to the expansion of private primary care doctors (for those who can afford them!). Finally, it is leading to the development of new approaches to primary care using IT. One initiative that has been causing a stir is “GP at Hand” which launched in London at the end of 2017. This offers immediate access to a GP via a telephone app and face to face consultations if required. Thousands of (predominantly younger people have already signed up.
The functioning and structure of primary care in times of limited resources needs a rethink so that it can properly carry out its role. At the moment in many places GPs are no longer acting as gatekeepers to the healthcare system – ushering people in and directing them on where to go. In practice, they are functioning more like bouncers, blocking many people from access to the healthcare they need.
 This is the general rule but is not necessarily the case everywhere, especially where the private sector plays a large role in healthcare.