What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services?

Summary

The issue

Governments are searching for ways to improve the equity, efficiency, effectiveness, and responsiveness of their health systems. In recent years there has been an acceptance of the important role of primary health care in helping to achieve these aims. However, there have been no systematic reviews on primary care versus specialist-oriented systems, nor has the case for primary health care been firmly established.

This review presents the evidence for the advantages and disadvantages of restructuring a health care system on primary care services. It is based on a rapid but systematic review of key sources of published literature. The evaluation of evidence is complex for a number of reasons, including differing definitions of services, staff and the boundaries between primary and secondary care, changing organizational structures, and an increasing reliance on primary care teams. No studies were found that specifically addressed the advantages of health care systems relying on specialists.

Findings

International studies show that the strength of a country’s primary care system is associated with improved population health outcomes for all-cause mortality, all-cause premature mortality, and cause-specific premature mortality from major respiratory and cardiovascular diseases. This relationship is significant after controlling for determinants of population health at the macro-level (GDP per capita, total physicians per one thousand population, percentage of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption). Furthermore, increased availability of primary health care is associated with higher patient satisfaction and reduced aggregate health care spending. Studies from developed countries demonstrate that an orientation towards a specialist-based system enforces inequity in access. Health systems in low income countries with a strong primary care orientation tend to be more pro-poor, equitable and accessible. At the operational level, the majority of studies comparing services that could be delivered as either primary health care or specialist services show that using primary care physicians reduces costs, and increases patient satisfaction with no adverse effects on quality of care or patient outcomes. The majority of studies analysing substitution of some services from secondary to primary care showed some such shifts to be more cost-effective. The expansion of primary health care services may not always reduce costs because it ends up identifying previously unmet needs, improves access, and tends to expand service utilization.

Policy considerations

The available evidence demonstrates some advantages for health systems that rely relatively more on primary health care and general practice in comparison with systems more based on specialist care in terms of better population health outcomes, improved equity, access and continuity and lower cost. However, a stronger evidence base is needed to make the evidence available universally applicable.