Intended for healthcare professionals


Quality in primary health care: a multidimensional approach to complexity

BMJ 2009; 338 doi: (Published 02 April 2009) Cite this as: BMJ 2009;338:b1242
  1. Iona Heath, general practitioner1,
  2. Adolfo Rubinstein, professor of family medicine and public health2, president3,
  3. Kurt C Stange, professor of family medicine, epidemiology and biostatistics, sociology, and oncology4,
  4. Mieke L van Driel, professor of general practice56
  1. 1Caversham Group Practice, London NW5 2UP
  2. 2Division of Family and Community Medicine, Hospital Italiano, Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
  3. 3Institute of Clinical Effectiveness and Health Policy, Buenos Aires
  4. 4Case Western Reserve University, Cleveland, OH 44106, USA
  5. 5Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld 4229, Australia
  6. 6Department of General Practice and Primary Health Care, Ghent University, Ghent, Belgium
  1. Correspondence to: I Heath iona.heath{at}
  • Accepted 1 December 2008

Good care is much more than meeting disease specific targets. Iona Heath and colleagues argue that assessments of quality must take into account all the complexities of primary health care

In his 1913 novel Chance, Joseph Conrad wrote about the changing fashion for certain words: “You know the power of words. We pass through periods dominated by this or that word—it may be development, or it may be competition, or education, or purity or efficiency or even sanctity. It is the word of the time.” Today’s word is quality.

In order to assess the quality of primary health care, we have to define what quality means in this context. But who should make the definition, and whose perspective should take priority? The easy assumption is that quality should be defined by patients rather than by policymakers, politicians, or healthcare professionals—but who is the representative patient? How generalisable can any measure of the quality of primary health care be across different economic, social, and cultural contexts?

What makes good care?

The process and structure of primary care are highly dependent on the nature of each society and its healthcare system.1 Thus, the traditional Donabedian approach to assessing quality based on structure, process, and outcome2 is relevant to primary care but must take into account the diversity that results from primary care’s adaptability. Efforts to improve quality by reducing undesirable variability in the delivery of services must also avoid reducing desirable variability that reflects personalising, integrating, and prioritising care.

Effective primary care depends on the integration of both vertical and horizontal care. Vertically oriented care concerns the management of specific diseases from primary to tertiary care, whereas horizontally oriented care emphasises the integration of care around the needs of individuals and the design of systems of care that focus on the broad needs …

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