Primary Health Care E-Book

Trisha Greenhalgh

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 679

Veröffentlichungsjahr: 2013

Beschreibung

General practitioners and other primary care professionals have a leading role in contemporary health care, which Trisha Greenhalgh explores in this highly praised new text. She provides perceptive and engaging insights into primary health care, focussing on:

• its intellectual roots
• its impact on the individual, the family and the community
• the role of the multidisciplinary team
• contemporary topics such as homelessness, ethnic health and electronic records.

Concise summaries, highlighted boxes, extensive referencing and a dedicated section on effective learning make this essential reading for postgraduate students, tutors and researchers in primary care.

"Trish Greenhalgh, in her frequent columns in the British Medical Journal…more than any other medical journalist spoke to her fellow GPs in the language of experience, but never without linking this to our expanding knowledge from the whole of human science.

When I compare the outlines of primary care so lucidly presented in this wonderful book, obviously derived from rich experience of real teaching and learning, with the grand guignol theatre of London medical schools when I was a student 1947-52, the advance is stunning."
—From the foreword by Julian Tudor Hart

"Trish Greenhalgh is one of the international stars of general practice and a very clever thinker. This new book is a wonderful resource for primary health care and general practice. Every general practice registrar should read this book and so should every general practice teacher and primary care researcher."
—Professor Michael Kidd, Head of the Department of General Practice, University of Sydney and Immediate Past President of The Royal Australian College of General Practitioners

"This important new book by one of primary care's most accomplished authors sets out clearly the academic basis for further developments in primary health care. Health systems will only function effectively if they recognise the importance of high quality primary care so I strongly recommend this book to students, teachers, researchers, practitioners and policy makers."
—Professor Martin Marshall, Deputy Chief Medical Officer, Department of Health, UK

Leseprobe

Contents

Acknowledgements

Preface

Foreword

1 Introduction

1.1 What is primary (health) care?

1.2 What is academic study?

1.3 What are theories – and why do we need them?

2 The ‘ologies’ (underpinning academic disciplines) of primary health care

2.1 Biomedical sciences

2.2 Epidemiology

2.3 Psychology

2.4 Sociology

2.5 Anthropology

2.6 Literary theory

2.7 Philosophy and ethics

2.8 Pedagogy

3 Research methods for primary health care

3.1 What is good research in primary health care?

3.2 Qualitative research

3.3 Quantitative research

3.4 Questionnaire research

3.5 Participatory (‘action’) research

3.6 Research data – and analysing it

3.7 Critical appraisal of published research papers

3.8 Systematic review

3.9 Multi-level approaches to primary care problems

4 The person who is ill

4.1 The sick role

4.2 The illness narrative

4.3 Lifestyle choices and ‘changing behaviour’

4.4 Self-management

4.5 Health literacy

5 The primary care clinician

5.1 The role of the generalist

5.2 Clinical method I: rationalism and Bayes’ theorem

5.3 Clinical method II: humanism and intuition

5.4 Clinical method III: the patient-centred method

5.5 Influencing clinicians’ behaviour

5.6 The ‘good’ clinician

6 The clinical interaction

6.1 The clinical interaction I: a psychological perspective

6.2 The clinical interaction II: a sociolinguistic perspective

6.3 The clinical interaction III: a psychodynamic perspective

6.4 The clinical interaction IV: a literary perspective

6.5 The interpreted consultation

7 The family – or lack of one

7.1 Family structure in the late modern world

7.2 The mother–child relationship (or will any significant other do these days?)

7.3 Illness in the family – nature, nurture and culture

7.4 Homelessness

8 The population

8.1 Describing disease in populations

8.2 Explaining the ‘causes’ of disease

8.3 Detecting disease in populations

8.4 ‘Risk’: an epidemiological can of worms?

9 The community

9.1 Unpacking health inequalities I: deprivation

9.2 Unpacking health inequalities II: social networks and social capital

9.3 Unpacking health inequalities III: life course epidemiology and ‘risk regulators’

9.4 Developing healthy communities I: community oriented primary care

9.5 Developing healthy communities II: participatory approaches

10 Complex problems in a complex system

10.1 Illness in the twenty-first century: chronicity, comorbidity and the need for coordination

10.2 Coordinating care across professional and organisational boundaries

10.3 The electronic patient record: a road map for seamless care?

10.4 The end of an era?

11 Quality

11.1 Defining and measuring quality

11.2 A rational biomedical perspective: evidence-based targets, planned change and criterion-based audit

11.3 A narrative perspective: significant event audit

11.4 A social learning perspective: peer review groups and quality circles

11.5 A phenomenological perspective: the patient as mystery shopper

11.6 A sociological perspective: Quality Team Development as organisational sensemaking

Index

© 2007 Trisha Greenhalgh

Published by Blackwell Publishing

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First published 2007

1 2007

Library of Congress Cataloging-in-Publication Data

Greenhalgh, Trisha.

Primary health care: from academic foundations to contemporary practice / Trisha Greenhalgh.

p. ; cm.

“BMJ books.”

Includes bibliographical references and index.

ISBN 978-0-7279-1785-0 (pbk.: alk. paper)

1. Primary care (Medicine) I. Title.

[DNLM: 1. Primary Health Care. 2. Health Services Research. W 84.6 G813p 2007]

RA427.9.G74 2007

362.1–dc22

2007003618

ISBN: 978-0-7279-1785-0

A catalogue record for this title is available from the British Library

Commissioning Editor: Mary Banks

Editorial Assistant: Victoria Pittman

Development Editor: Lauren Brindley

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For further information on Blackwell Publishing, visit our website: http://www.blackwellpublishing.com

Blackwell Publishing makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check that any product mentioned in this publication is used in accordance with the prescribing information prepared by the manufacturers. The author and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this book.

To my students, who expected me to write this book.

Acknowledgements

This book is my own work, and I alone take responsibility for errors and omissions. It would not have been possible for me to tackle the vast field of primary health care without inspiration, insights and contributions from dozens if not hundreds of academic and clinical colleagues. Many of these people are mentioned by name in the sections of this book where their input has been direct, explicit and auditable. But I am also indebted to the numerous colleagues and students who have provided more subtle, indirect and diffuse input to my knowledge and understanding of primary health care over the years. They are, quite literally, too numerous to list in full. I hesitate to single out any individual or group for special mention because my debt to the academic community is so extensive, but I must acknowledge in particular my outstanding team of tutors on the online MSc in International Primary Health Care at University College London, with whom it is a privilege and a joy to work.

Thanks also to Mary Banks and her team at Blackwell Publishing for the unrivalled quality of their support in taking this book from an idea on the back of an envelope to the finished product. They have seen the work go through many metamorphoses. And finally, to my long-suffering husband Fraser Macfarlane and sons Rob and Al for their forbearance, patience and support as the magnum opus slowly took shape.

Preface

In 1999, the editor of the Lancet, Dr Richard Horton, threw down this gauntlet:

‘Primary care is the subject of more charters, declarations, manifestos, and principles than any other medical discipline, except perhaps its similarly plagued cousin, public health. Yet this efflux of ruminations from worthy experts and respected bureaucracies has contributed hardly anything to the daily practice of family medicine’.1

Horton’s words were met with outrage from primary care academics worldwide, and I certainly shared that outrage. But his editorial revealed two important things. First, that the academic foundations of primary care, if not weakly developed in themselves (and perhaps they were), had been poorly articulated by academics within our discipline. Second, that these foundations were, as a result, widely and profoundly misunderstood by people in powerful positions in academia and medical publishing. It was Horton’s shot across the bows that prompted me to take on the task of producing a completely new, single-author textbook on the academic basis of primary health care.

The case for such a book was not difficult to make. Remarkably few academic textbooks in this field have ever been written – and to my knowledge, no new first editions have been published in the past 15 years. The giants on whose shoulders I stand include Britain’s William Pickles (Epidemiology in Country Practice, originally published in 19392) and Julian Tudor Hart (A New Kind of Doctor, 19883); Hungary’s émigré to Britain Michael Balint (The Doctor, His Patient and the Illness, 19564); America’s Barbara Starfield (Primary Care, 19925) and Robert Rakel (Textbook of Family Medicine, 19736) and Canada’s Ian McWhinney (A Textbook of Family Medicine, 19867).* I have also been inspired by Gillian Hampson’s excellent textbook for nurses, Practice Nurse Handbook, first published as Bolden and Tackle’s Handbook in 1980.9

Apart from more up-to-date reference lists, what does this book offer that goes beyond what the greats of a generation ago came up with? First and foremost, I have deliberately devoted a large section of the book to disentangling the diverse disciplinary roots of primary health care. Pickles, Fry and Starfield took an almost exclusively epidemiological perspective and showed how such a perspective could both emerge from and serve to inform the work of the primary care team. Balint focused on the psychodynamic perspective and showed how this could illuminate the study of the doctor–patient relationship. Tudor Hart linked epidemiology with political science and drew links between social inequalities and health outcomes. McWhinney, to whom I owe a particular intellectual debt,† drew on a range of disciplines including epidemiology, psychology and moral philosophy, but did so in a way that produced a unified, multi-level theory (patient-centred medicine; see Section 5.4) rather than – as I have chosen to do – setting out a menu of different disciplinary and theoretical perspectives as possible ‘options’ for cutting the cake of primary care. It is on McWhinney’s important early work, and with the advantage of the last decade in which primary care has matured considerably as an academic field in its own right, that I seek to build.

I have called Chapter 2 ‘The “ologies” of Primary Health Care’ because I believe that no single ‘ology’ (be it basic biomedical science, epidemiology, psychology, sociology, anthropology or philosophy) can alone underpin either practice or research in primary care. What is needed is not a single, ‘minestrone’ discipline that primary care can call its own, but a greater recognition by practitioners and researchers that different primary disciplines provide different theoretical lenses through which the complex and multifaceted problems of primary care can be studied. As I explain in Chapter 2, identifying the right ‘ology’ for a particular primary care problem is one of the key skills of the academic practitioner.

The second unique feature of this book is that it is (to my knowledge) the first general, single-author academic textbook to take an explicitly multiprofessional perspective on primary health care (as opposed to general practice or family medicine). The shift from uniprofessional to multi-professional focus reflects changes in the organisation of primary care over the past 20 years and in the diverse roles associated with its delivery – particularly the growth of primary care nursing. It also reflects, I guess, the increasing role of the person who is ill in his or her own care, since the ‘expert patient’ (see Section 4.4) is also a member of the multi-professional team. Only around half the students on my MSc course in International Primary Health Care (www.internationalprimaryhealthcare.org) are medically qualified; the remainder have backgrounds in nursing, health policy, pharmacy, social work, physiotherapy and management. As I emphasise in Chapter 10, illness in the twenty-first century is characterised by complexity, comorbidity and the need for coordination. In this context, textbooks aimed exclusively at a single professional group are increasingly anachronistic.

The third unique selling point of this book is that every word has been written by a single author. There is a touch of irony here. If primary care is so intellectually diverse, so clinically and organisationally complex and its practice necessarily multi-professional, surely it would be better to include an appropriate range of individuals as chapter authors, each of whom would cover a particular area of expertise. There are certainly some advantages to such an approach – for one thing, the subject matter would be covered more evenly and comprehensively. As it is, this textbook is biased towards my own areas of interest and expertise (sociological aspects of illness and healthcare, ethnic health, electronic records) and somewhat superficial on other areas (such as epidemiological databases). But the upside is – I hope – that this book offers a holistic overview of the field along with consistency of style that simply cannot be achieved in a multi-author textbook. Incidentally, a massive, multi-author reference textbook on primary health care has recently been published in the UK,10 and an equally weighty European Textbook of Family Medicine has recently rolled off the press. I do not seek to compete directly with these tomes, but to supplement them with one woman’s take on the parameters of our discipline.

Having said that, I make no claim to comprehensiveness. In a field as diverse and rapidly changing as primary health care, any attempt at encyclopaedic coverage of its multitudinous themes in a single volume is doomed to failure, and in any case the academic journals make a much better job of covering all the latest topics. Like McWhinney before me, I have sought to produce a ‘territory map’ of academic primary care along with some illustrative examples of how theory and method may be applied to the huge range of potential research topics. Though necessarily incomplete and distorted by my personal interests and prejudices, I hope this map will prove sufficiently coherent to convey the breadth of what counts as the ‘normal science’ of academic primary health care and sufficiently flexible to accommodate perspectives and theories that I have missed (or which are yet to emerge).

What, then, is my intended audience for this book? To paraphrase John Van Maanen, any book that aspires to the status of academic work has three potential audiences:11

1 Scholars in the field. This book is written primarily for people who are already working as academics in primary health care or who aspire to enter the field as researchers or teachers. These are the people who, by and large, see the subject matter of primary health care through similar eyes to mine, who already know (or are learning) the jargon, who share (or are coming to share) the assumptions and are familiar with the main theories and methods used in primary care research. Included in this group are students (PhD, MSc and ambitious undergraduates) who seek to define, with a view to extending, the margins of knowledge in primary care.

2 Thinking practitioners. This book is also intended for general practitioners, practice and community nurses, and other primary care professionals who wish – for personal fulfilment or career progression – to go beyond the multitude of books on the shelves that promise ‘ten tips for better consulting’ or ‘how to organise your practice.’ The examination for the Membership of the Royal College of General Practitioners (www.rcgp.org) now includes an understanding of research and the academic basis of general practice in its syllabus. But be warned: I did not set out to write a textbook for the Membership of the Royal College of General Practitioners, nor have I consulted or collaborated with its Board of Examiners, so do not take my word for what will come up in the exam or what the ‘right’ answers will be deemed to be.

3 General readers. Finally, this book is intended for people – especially in other academic disciplines – who have not the faintest idea what primary health care is and have even less clue about its academic basis. Primary health care is (like education, human resource management and in-flight catering) an applied field of study. Its main subject matter is not a unique set of abstract premises and theories nor a set of observations made in the pure environment of the laboratory, but the messy reality of the real world with all its complexity and situational contingencies. As the opening quote of this Preface illustrates, the academic basis for applied fields is harder for outsiders to grasp, not least because so many practitioners within those fields are unclear about the concepts and theories that inform (often implicitly) the work that they do. It follows that those of us who hold tenured professorships in applied fields must spend at least some of our Sunday afternoons setting out our stall in a way that academics from the traditional ‘ologies’ can begin to take this seriously. I hope that, in this book, I have begun to address that task.

One final comment about the intended audience for this book: I live and work in the UK, and many (though by no means all) of my examples are taken from my own direct experience. This means that this book will perhaps be more meaningful to readers who are based in the UK. But this book is also intended as the course textbook in an international Masters course that takes students from (so far) four continents and 17 different countries. Whilst I use local examples at both micro level (e.g. the primary care consultation as it generally happens in the UK) and macro level (UK health policy or funding arrangements), I have presented these as examples, and have deliberately tried to select ones that provide transferable insights for students from other countries. I hope, therefore, that this book will prove useful to an international audience, and I would be especially keen to receive suggestions for meeting the needs of this wider audience should the book run (dare I say it) to a second edition.

Trisha Greenhalgh OBEUniversity College LondonMarch 2007

References

1 Horton R. Evidence and primary care. Lancet 1999;353:609–610.

2 Pickles W. Epidemiology in Country Practice. Bristol: John Wright; 1939.

3 Hart JT. A New Kind of Doctor. London: Merlin Press; 1988.

4 Balint M. The Doctor, His Patient and the Illness. London: Routledge; 1956.

5 Starfield B. Primary Care: Balancing Health Needs, Services and Technology. New York: Oxford University Press; 1992.

6 Rakel R. Textbook of Family Medicine. 1st edn. New York: Elsevir; 1973.

7 McWhinney IR. A Textbook of Family Medicine. 1st edn. Oxford: Oxford University Press; 1986.

8 Noble JH, Greene HL, Levinson W, et al. Textbook of Primary Care Medicine. 3rd edn. New York: Mosby; 2000.

9 Hampson G. Practice Nurse Handbook. 5th edn. Oxford: Blackwell; 2006.

10 Jones R, Grol R, Britten N, et al. Oxford Textbook of Primary Medical Care. Oxford: Oxford University Press; 2004.

11 Van Maanen J. Tales of the Field: On Writing Ethnography. Chicago, IL: University of Chicago Press; 1986.

* I should also mention John Noble and team’s Primary Care Medicine, the leading US textbook, which is an excellent overview of the clinical problems seen in primary care practice, along with a guide to evidence-based decision making.8 This is an outstanding reference tome for doctors in clinical practice, but does not attempt to cover the breadth of interdisciplinary territory addressed here. Another comprehensive textbook written for a US audience is Rakel’s Textbook of Family Medicine, first published in 1973 and now in its 7th edition.6 While mainly centring on clinical problems, it includes sections on evidence-based medicine and also covers the important work of McWhinney.

† That is not to say that I regard the contribution of the other authors listed here as less intellectually significant, but that my own take on academic primary care aligns most closely to that of McWhinney and his team.

Foreword

In 1974, as a working GP in what was then still a functioning colliery village, I was invited to lecture on primary care at Johns Hopkins University Hospital in Baltimore. This was an awesome responsibility. Johns Hopkins was the place where Sir William Osler and William Henry Welch added Rockefeller’s oil fortune to German laboratory science, thus realising in practice Abraham Flexner’s dream of medical education founded on hospital specialism and scientific evidence.1 This set a world gold standard pattern for medical education which even today remains largely intact.

True, I was only invited by the Department of Public Health, which, though distinguished in its own right, was still considered by all other faculties as only a minor adjunct to clinical medicine and surgery. And of course there was no department at all for general practice, family medicine, or any other concept of primary health care. However, the phrase “primary care” itself had suddenly become fashionable. Kerr L. White, then at Chapel Hill, North Carolina, had shown that in one average month, out of 1000 adult US citizens at risk, 750 had some sort of illness, 250 consulted any sort of doctor, 9 were admitted to any sort of hospital, and only 1 actually reached a teaching hospital to provide case-material for learning. He originally got this idea from John and Elizabeth Horder’s referral data, from the James Wigg practice in Kentish Town.2 Consultants in teaching hospitals ignored at their peril mounting evidence that existence of cost-effective generalists was a precondition for their own survival as real specialists, rather than “specialoids’’ – doctors claiming specialist fees but without effective hospital support. That useful term was coined by John Fry3, one of the first to recognise this truth. It was confirmed by a report from the American College of Cardiology, which found that though in Boston, Miami and New York there were more than 10 cardiologists per 100,000 population, 70% of these had office-based rather than hospital-based practices, and half were not specialist Board-certified.4 In a market economy, health workers closest to technology make the most money, and nobody wants either to be a generalist, or to provide continuing care.

So before my lecture I was shown around Johns Hopkins Hospital. Like most large hospitals, its ground floor was built around an exhausting and apparently endless corridor, with a network of pipes and cables running along its ceiling. As we approached somewhere about halfway along this corridor I saw a roughly cut cardboard sign hanging from bits of string looped around the pipes. And this is what it said:

DEPARTMENT OF PRIMARY CARE→

My guide was intrigued – he had never noticed it before. We followed the arrow, and found ourselves in the Emergency Room. It was heaving with the sort of events one sees on television doctordramas – children with acute severe asthma whose parents had never been told the difference between a ’preventer’ and ’reliever’; diabetic patients in ketoacidosis whose medication had not been reviewed for years; overweight men rigid with low back pain who had never received advice or physiotherapy; elderly people whose undetected hypertension had led to a massive stroke; and smokers whose unchecked habit had finally caused them to cough up blood. These everyday ‘emergencies’ would occur very rarely in a country with a developed primary care system accessible to the whole population. The barbarism of the scene was confirmed by the presence of several heavily armed policemen. The doctors and nurses confirmed that their work had indeed just been renamed, in tune with fashion. New words, unchanged resources.

I tell this story first to establish two points, and then to draw an important conclusion for the many thousands of students who will use this book, in this first edition and the many others which surely will follow.

First, even in the USA, things have moved on since then, as is the nature of market economies. Specialoids have not been eliminated, but they have been pushed back – by the mighty force of corporate investors in health care, whose profits depend on rationalising the processes of commodity production, and have no interest in maximising doctors’ incomes. So things get rapidly better, and even if people get worse, more and more things can be done to repair them. In Britain, where until 1979 the National Health Service, and the medical schools producing its doctors, all operated as a gift economy outside and above the market, both things (medical and nursing knowledge and resources) and people (staff and patients) steadily improved, even though both service and teaching functions were always grossly under-resourced. In USA in the early 1980s, one single department of family medicine in Worcester, Massachusetts, employed more staff than all the UK departments of primary care and general practice put together. Our health professionals learned how to listen and talk to patients as if they were friends, neither customers to be flattered nor sheep to be herded. Among their most impressive teachers was Trish Greenhalgh, in her frequent columns in the British Medical Journal. More than any other medical journalist, she spoke to her fellow GPs in the language of experience, but never without linking this to our expanding knowledge from the whole of human science.

When I compare the outlines of primary care so lucidly presented in this wonderful book, obviously derived from rich experience of real teaching and learning, with the grand guignol theatre of London medical schools when I was a student 1947–52, the advance is stunning. Young health workers today are incomparably better educated than they were in my immediately postwar generation, and from what I see of mature students entering medicine at Swansea Clinical School, they are now moving ahead faster than ever before. They know more of what really matters, the body of knowledge from which they draw is larger, simpler, and much more effective, and their attitudes to patients are hugely more sensitive and better informed.

But here we reach my second point. Students in every advanced economy now face an imminent future in which technology will certainly go on improving, but human relationships are rapidly getting worse. In 1996, even before we got incontrovertible evidence of approaching environmental crisis, the United Nations report on human development showed that the world then contained 358 people with one billion or more US dollars. Their total wealth equalled the combined incomes of the poorest 45% of the world population.5 Disproportionate wealth on this scale creates equally disproportionate power. Health care systems in almost all countries, whatever their stage in economic development, have been conscripted to a single market-oriented pattern determined by the World Bank, which now has a far bigger health budget than the United Nations’ World Health Organization.

Students of anatomy will not find what has become the most potent of all human organs, the wallet. The market decides. Even if all these 358 billionaires were angels, determined to address the needs of all people rather than such wants as are profitable, they must maximise their cash returns on investment. If they do not, their corporations will be devoured by competitors.

So the irresistible force of advancing scientific knowledge collides with the immovable object of a global economy in which meeting global needs is allowed to proceed only as a byproduct of making very rich people richer still.6 They say our world began with a big bang. Unless your generation recognises the difference between natural laws, which cannot be changed, and human laws (including those of economics) which arise from human decisions and behaviour, that may be how it will end. Students today will have to learn, and later to apply their learning, within contexts of crisis no less profound than that from which my generation only just managed to emerge in 1945. Some of the social relationships already established in the pre-“reform” NHS, which were a precondition for developing the ideas and practice outlined in this book, could still provide foundations for rebirth of the honesty and hope we now desperately need.

Julian Tudor Hart

References

1 Berliner HS. A larger perspective on the Flexner report. Int J Health Serv 1975;5:573–592.

2 White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885–892. He acknowledged his debt to the Horders in White KL, Frenk J, Ordoñez C, Paganini JM, Starfield B (eds). Health Services Research: An Anthology, Vol. 534. Pan American Health Organization Scientific Publication; 1992:217–226.

3 Fry J. Medicine in Three Societies: A Comparison of Medical Care in the USSR, USA and UK. Aylesbury, Bucks: MTP; 1969.

4 Lancet 1974;i:617.

5 Jolly R (ed.). United Nations Report on Human Development, 1996.

6 Hart JT. The Political Economy of Health Care: A Clinical Perspective. Bristol: Policy Press, 2006.

CHAPTER 1

Introduction

Summary points

1 Primary health care has many definitions. Most of them include the following dimensions: first-contact care; undifferentiated by age, gender or disease; continuity over time; coordinated within and across sectors; and with a focus on both the individual and the population/community.

2 In the twenty-first century, traditional academic skills (the ability to think logically, argue coherently, judge dispassionately and solve problems creatively) must be supplemented by contemporary academic skills (communication, interdisciplinary teamwork, knowledge management and adaptability to change).

3 Primary care is an applied (secondary) discipline and its study is problemoriented. It does not have a discrete scientific paradigm to call its own. Rather, it draws eclectically on a range of underpinning primary disciplines (which will be discussed further in Chapter 2).

4 Different problems in primary care require different perspectives, based on different conceptual and theoretical models. It will never be possible to come up with a single ‘unifying theory’ that explains all aspects of primary care. Studying different theories can help illuminate why different people look at (and try to solve) the ‘same’ primary care problem in different ways.

5 There is a tension between the typical ‘textbook definition’ of primary care (concerned with a tidy disease taxonomy, evidence-based treatments and a compliant patient in a stable family and social context) and its practical day-today reality (fragmented and changing populations, unclassifiable symptoms, absent or ambiguous evidence and mismatch of goals and values between clinician and patient). The academic study of primary care should not focus on the former at the expense of the latter.

1.1 What is primary (health) care?

We hear increasingly of a ‘primary care led health service’, ‘primary care based research’, ‘capacity building in primary care’ and ‘primary care focus’ for healthcare planning. But when we talk about primary (health) care, what exactly do we mean? Is primary care anything that occurs outside a hospital? What about a hospital-based walk-in service for minor illnesses? Is voluntary sector care (such as that provided by self-help charities) part of primary care? If a general practitioner (GP) or family doctor (or a general internist in the USA) provides specialist services, does that still count as ‘primary’ care? And, frankly, does it matter? Instead of chasing a tight definition of primary care and enforcing it across all countries and healthcare systems, would we be better off with flexible parameters that can be applied with judgement in different contexts?

Let’s start with a working definition and see how it stands up to closer scrutiny.

Primary health care is what happens when someone who is ill (or who thinks he or she is ill or who wants to avoid getting ill) consults a health professional in a community setting for advice, tests, treatment or referral to specialist care.

An obvious primary care contact is a visit to the general medical practitioner or GP (referred to in some countries as the family practitioner or family doctor), ∗ for example, with an episode of acute illness, for ongoing care of a long-term health problem or for a check-up or screening test. But primary care in the UK – and in many other countries – also includes pharmacy services, community-based nursing services, optometry and dental care. It includes not merely the acute care that sick persons might receive they enter hospital with a serious illness (such as a stroke or diabetic emergency), but also the care they receive discharge – rehabilitation, ongoing education and support, and continuing surveillance of their chronic condition.