Intended for healthcare professionals

Sacred Cows

The primacy of primary health care

BMJ 1998; 317 doi: (Published 19 December 1998) Cite this as: BMJ 1998;317:1724
  1. J R Hampton, professor of cardiology
  1. Cardiovascular Medicine, University Hospital, Nottingham NG7 2UH

    General practice is unarguably one of the great strengths of British medicine, but the concept of the primacy of primary health care must be seen for what it is—another attempt at cost containment. The lunatic reorganisation of the NHS by Kenneth Clarke, which aimed to reduce costs by creating fundholding general practitioners and setting one hospital against another in spurious competition, was the primacy of management. It failed because it was manifestly unfair to patients, created strife between hospitals that had no spare capacity for proper competition, and spawned a huge increase in the management culture. The new reorganisation into supreme primary care groups, designed to be independent of hospital trusts, is unlikely to lead to much improvement, for it rests on the same premise—that cost can be controlled only by maintaining the conflict between purchaser and provider. District general hospitals dealing with several primary care groups will have just as many problems as they had when their purchasers comprised a mixture of fundholding practices and one or two health authorities.

    In an age of evidence based medicine, organisational structures seem to be immune from experiment and are therefore changed without evidence of benefit. There is no evidence that an NHS based on the primacy of primary care will function any better than one devoted to the primacy of management. Those in primary care are still encouraged to see a 1930s-style fight against the citadel of hospital supremacy, while those in the hospital sector still see only management manipulating figures to make overspending seem less than it is.

    Primacy of secondary care?

    A much better case can be made for the primacy of secondary health care. The secondary sector deals with major illness, which concerns patients most. The inexorable rise in admissions for medical emergencies shows clearly what patients want, and presumably general practitioners see the importance of secondary care too or more patients would be kept at home. An increasingly litigious society and increasing practice of defensive medicine accentuate the primacy of secondary care.

    Secondary care is responsible for most of the evidence on which the practice of medicine is now meant to be based. This is inevitable because only in the secondary sector are patients with particular diseases sufficiently concentrated to make clinical trials possible. The underfunded NHS already fails to provide the care that the secondary sector has shown to be beneficial, so why talk about the primacy of primary care? Resources need to follow clinical benefit, and an emphasis on primary care will inevitably slow medical advance.

    We cannot be confident that the primary sector will accurately predict the need for secondary care. Doctors in primary care see many patients who need cataract and hip operations and a few who have heart attacks, and they will inevitably overemphasise the importance of common conditions. General practitioners see almost no patients with rare and difficult problems, such as systemic lupus erythematosus, which need specialist care. Only a major hospital, drawing its patients from a large population, sees the true picture of important ill health and ensures that patients with rare diseases are not discriminated against. In a position of primacy there is a danger that the primary care sector will dissipate its efforts into primary prevention of disease, with those who are politically correct pointing to the need to stop smoking, reduce stress in the work place, and stop bullying at school. All these objectives are without doubt highly desirable, but they should not be the province of medical practitioners with a decade of training. The treatment of important illness must be the first priority.

    The primacy of secondary care is a perfectly viable alternative to the primacy of primary care. The secondary sector can lead primary care groups on a hub and spoke basis. We must assume that the provision of medical care will remain rationed, and it therefore makes sense to put the primacy of care—which means control of funding—into the sector that can make best use of it.

    Cooperation is crucial

    But the truth is we do not need primacy at all: we need cooperation. Illness does not divide itself neatly into primary and secondary types—a patient will move back and forth between primary and secondary care many times using inpatient and outpatient facilities as necessary. We need to find ways of promoting understanding and cooperation between the two parts of the system, and this must start with education and training. Vocational training schemes for general practice require periods in hospital, and rotations designed for a hospital career for senior house officers and specialist registrars should include periods in general practice. Only when each side fully understands the other's problems will the harm caused by words such as primacy be understood. A properly organised amalgam of primary and secondary care doctors could, without any help from a district health authority, decide how rationed health care can best be delivered to a community. But sucha group would need a focus, and that focus should be the district general hospital.

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