Shifting the balance from secondary to primary careBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7018.1447 (Published 02 December 1995) Cite this as: BMJ 1995;311:1447
- Angela Coulter
- Director King's Fund Development Centre, London W1M 0AN
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 …