Shifting the balance from secondary to primary care

Needs investment and cultural change

Countries with more highly developed systems of primary care tend to have lower health care costs,1 and policies designed to shift the balance from secondary to primary care have therefore been a common theme in health service reforms. But financial motives are not the only reason. Starfield's definition of primary care—“first-contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease or organ system”1—encapsulates the main elements that such policies aim to preserve. A health care system dominated by secondary, tertiary, and emergency care will tend to be fragmented, discontinuous, uncoordinated, and costly.

In Britain, boundaries are already shifting. Some procedures are being transferred from hospital to community settings. For example, triage systems and hospital at home schemes are being established to avoid hospital admissions and facilitate early discharge; attempts are being made to reduce the number of patients referred inappropriately to specialist services by developing and implementing referral guidelines; general practitioners and community nurses are being encouraged to develop new skills and new practice based facilities; shared care schemes are being introduced for chronic disease management, paediatrics, mental health, and maternity care; and some general practitioners and specialists are experimenting with direct booking to surgical waiting lists, avoiding the need for specialist outpatient consultations.

To what extent will these developments succeed both in improving patient care and in achieving a real shift in the balance of care? Hard pressed primary care staff do not usually welcome additions to their workload unless these are accompanied by new resources. If resources are to be released for investment in primary care, there will have to be a reduced demand for hospital care; this means that the new primary care services will have to substitute for secondary care by catering effectively for patients who would otherwise have been referred to specialists. As yet there is little evidence that developments in primary care are reducing the demand for secondary care.

In recent years British general practitioners have been given financial incentives to perform minor operations in their practices. The hope has been that, by removing this workload from the hospital, waiting times could be reduced for both minor and major operations, but evaluation of this policy has so far shown no impact on the demand for hospital based minor surgery.2 Instead it seems that general practitioners' willingness to perform these procedures has encouraged patients to come forward for treatment who would not otherwise have done so. The increased availability of equipment for near patient diagnostic testing in general practices has had a similarly disappointing impact on demand for hospital services. Rink et al found that after practice based equipment for two biological and four biochemical tests was introduced to 12 practices the rates of investigation went up and costs increased.3 General practitioners seemed to be using the practice equipment as an addition to, rather than a substitute for, hospital laboratory investigations.

May not be easy or cost effective

The general practice fundholding scheme is the most comprehensive attempt to date to shift the balance of power, and hence to shift resources, to primary care. Fundholders have used their financial leverage to achieve a number of beneficial changes, including investing in practice based services such as physiotherapy, counselling, and diagnostic equipment.4 Although some fundholders have made savings in their hospital budgets, their rates of outpatient referral and hospital admission are as high as those of their nonfundholding colleagues and are still rising.^5,6 The investment by fundholders in new practice based services has not reduced the demand for specialist care. It is clear from these examples that achieving a shift in the balance of care is not going to be easy, and it is not even certain that it will prove to be cost effective. A recent review of the evidence on the effectiveness of shared care for diabetes found no advantage for patients over hospital care,7 and costs of well organised diabetes care in general practice are often higher.8 The Grampian study of integrated care for patients with asthma also found no difference in clinical outcomes between those receiving integrated care and those having conventional outpatient care, although costs were slightly lower for the shared care group.9

Changes are occurring, but their effect on the overall balance is at best marginal. Perhaps the gatekeeper role of British general practitioners already delivers the nearest thing to an optimal balance. Health care systems which allow patients direct access to specialists generally have higher rates of intervention and higher costs. A study in North Carolina found that patients with back pain who consulted orthopaedic surgeons or chiropractors incurred much greater costs than those who consulted primary care practitioners, but the outcomes of treatment in terms of functional recovery and return to work were similar in the three groups.10 The development of group practice health maintenance organisations, many of which incorporate a primary care gatekeeping role, has achieved appreciable cost reductions in the United States. It has also coincided with a resurgence of interest in general practice among American medical students.11

We know too little about the relative cost effectiveness of providing care in different settings and by professionals with different types of training. We also need to develop a better understanding of patients' needs and attitudes. There is some evidence that patients' expectations of the benefits and availability of specialist care are rising.12 Hospital closures are highly unpopular, and patients' perceptions of the need for specialist opinions can influence general practitioners' referral decisions.13 Primary care may not prove to be an acceptable substitute for secondary care in the popular imagination. There is a danger that consumer demand for increased access to specialists, coupled with commercial incentives for hospitals to induce demand for their services, will undermine the current trend towards primary care. If further shifts are to be secured, it will require a culture change among both professionals and the public.