CHAPTER 4 Primary health care system
Australia’s health system is dominated by hospitals and the provision of acute care and weighed down by a confusing maze of funding and administrative systems that dominate health budgets and political agendas. The media reflect the differing concerns of politicians, health professionals and the general public about costs and waiting lists, and access to quality care, especially the provision of beds in hospitals and nursing homes. Hospitals are challenged by the increasing demands for affordable, accessible health care, particularly for people with chronic and complex conditions (Doggett 2007) and the demand for new high-technology treatments. Nonetheless, the attention given to the functioning and maintenance of acute care systems is at the expense of community-based services which are concerned with front-line health care. Models of care in community services are called ‘primary health care’ and ‘primary care’, which incorporate prevention and early intervention.
This chapter explains the concepts of primary health care and primary care and explores the ways they are practised in community-based health services. The social model of health will be explained as the foundation of the movement in the social determinants of health which seek to address health inequities. These are the underpinnings of primary health care which will be compared and contrasted to the biomedical model of treatment and prevention which underpins primary care. It should be noted that the Ottawa Charter for Health Promotion was developed from the social model of health and this is explained further in Chapter 10. Concepts of ‘welfarism’ and universalism will be explored in the context of primary care, primary health care and community health.
Primary health care is a model of community-based health service delivery. It operates through a wide range of services such as Community Health Services (CHS), women’s health services, and youth health services. These services operate on a social model of health which is a conceptual framework built on understandings that improvements in health and wellbeing will only be achieved when we direct effort towards addressing the social, economic and environmental determinants of health.
Primary health care as a model of health care and as a philosophy, was articulated and documented at the first International Conference on Primary Health Care in 1978, held in the city of Alma-Ata (in what was then the USSR). The Declaration of Primary Health Care affirmed the principles of the social model of health in the following terms:
Pause for reflection
This vision for primary health care developed in 1978 was under attack almost as soon as the Alma Ata Conference was over (Hall & Taylor 2003) and in many respects, primary health care remains under attack. Politicians and medical ‘experts’ from developed countries have found it hard to accept the core primary health care principles that we need to reduce reliance on doctors and specialists, that communities can and should be involved in participatory decision making in the planning and implementation of programs and services that will benefit their health. At its core, primary health care is explicitly about addressing health equity, social justice, human rights and empowerment. This includes universal services, such as maternal and child health for which all mothers are eligible, to services for very marginalised groups, such as programs for the homeless or drug-using groups or comprehensive approaches to rehabilitation of people living with mental illness that might include treatment and medication management, counselling, employment support and education in basic living skills to enable independent living.
Primary health care is necessarily part of the publicly funded health system, provided at no cost to those who access services, and is not regarded as a ‘for-profit’ model of service delivery. Universal services like this are not part of the conservative, neo-liberal support for the privatisation of health services. Both primary health care policy and service delivery are driven by those core values mentioned above (social justice, human rights and equity) which are connected to the concepts of both ‘univeralism’ and ‘welfarism’. The connection is a shared concern with the health and welfare of all people but especially vulnerable groups: those with disadvantaged health and those living in poor circumstances or marginalised socially. Primary health care is necessarily provided in a multidisciplinary environment where there is commitment to the social model of health, at little or no cost to the end-user.
The next section discusses primary care, which is a term often interchanged with primary health care. However, there are essential differences between the two, although they form a continuum of care from treatment and disease management through to social determinants of health and disease which are discussed further in Figure 4.1.
The term ‘primary care’ was used as early as the 1920s in the Dawson report of the UK, which talked about a hub of services in a region operating through ‘primary health care centres’ (De Maseneer, Willems, Sutter et al 2007). Almost a century later, there is interest in the development of integrated primary care centres, providing GPs, dentists, nurses, pharmacists, physiotherapists, psychologists, specialists and other health services and providing pre- and post-hospital care, screening, education and other preventive health services (Doggett 2007).
Contemporary notions of primary care are derived from the biomedical model of diagnosis, treatment and care and equate with selective primary health care as shown in Figure 4.1. Sometimes primary care is a person’s first point of contact with the health system for a particular condition, although increasingly, hospital emergency departments are being used for that purpose. General practitioners, community nurses, and allied health practitioners are the most usual providers of primary care (Keleher 2001). Primary care is the frontline of disease prevention, screening and brief, opportunistic health education interventions. Secondary prevention is about timely treatment to prevent exacerbation of complications of disease or illness. Tertiary prevention is concerned with rehabilitation to restore health to the optimal possible state of health for that person.
Australia has a strong primary care sector based on general practices which mostly are aligned with one of the Divisions of General Practice that, in turn, are represented politically by the peak body, the Australian General Practice Network (AGPN). General practice is dominated by self-employed practitioners (Richardson, Walsh & Pegram 2005). In 2004–05, 85% of medical incomes were derived from Medicare or other insurers, such as Veterans Affairs, Transport Accident or Workcover, with the remaining 15% coming from out-of-pocket costs to patients.
Funding for multidisciplinary allied health services through general practice is by the Practice Incentives Program (PIP) which is available to accredited general practices that provide comprehensive, quality care. Practice Incentives Program payments support practices to employ practice nurses and allied health workers including dieticians, physiotherapists, and speech pathologists (Richardson et al 2005). In Section Two of this book a number of chapters explore these programs, particularly the Enhanced Primary Care packages.
Primary care services are also provided by a whole range of other private providers, such as physiotherapy and podiatry, and from other services that may receive some public funding for their operation, such as community-based nursing (sometimes called district or visiting nursing) services. Funding is provided to ensure community nursing services are provided at little or no cost to clients for what are seen as essential services, particularly in relation to the elderly. Home and Community Care (HACC) has particular aims about enabling older and frail aged clients to continue to live in their own homes.
Pause for reflection