Forget the specialists, focus on primary care

The key factor in the overall health of a community is affordable, accessible, high-quality primary care.

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‘Who’s the best knee man in town?? a friend asked. ?I need a really good dermatologist,? said another.

As a GP, I?ve become adept at fielding such questions, and I’ve long since given up explaining that choosing the ‘right’ specialist isn’t going to impact significantly on health outcomes in the vast majority of cases.

I’ve learnt few people are happy with such a response, and many firmly believe the health system’s problems would disappear if only we had more super-specialists, better staffed and equipped hospitals, shorter waiting times for elective surgery and a streamlined emergency department.

To read the newspapers, it appears the lay press and many of our specialist colleagues share the view that improving secondary and tertiary care and emergency services is the main path to a healthy community.

Of course, these issues need addressing, and more than once I’ve had a good whinge about the resources of my local hospital and emergency department. However, to focus almost exclusively on the so-called pointy end of health care delivery seriously misses the point.

So what does make for a healthy community?

According to US academic Dr Barbara Starfield, a pioneer researcher in this area, it’s certainly not more specialists.

Dr Starfield, a keynote speaker at last year’s Australian Divisions of General Practice (ADGP) conference, argues fervently against the commonly held view that access to high-powered specialists equates to best-quality care. Between 75 and 85 per cent of the population need only primary care services within a given year, she says. About 10-12 per cent require referral to secondary care for short-term consultation while between 5 and 10 per cent need a tertiary care specialist for a rare problem.

Although these figures will vary between time and place, her point is clear. Access to specialists is very important for those who genuinely need it, but ?unrestrained access to specialists for people who think they may need it is potentially dangerous, leading to unnecessary and potentially dangerous tests and therapies?. Evidence suggests that between 20 per cent and 30 per cent of patients receive contraindicated care ? that is, care that is not warranted and may even cause harm.

Dr Starfield believes that specialists are more efficient at dealing with some diseases, but by no means all. Furthermore, as all GPs can confirm, much of primary care practice focuses on problems that ?are not and may never be resolved to definitive diagnoses?.

In short, the key factor in the overall health of a community, according to a significant body of research, is affordable, accessible, high-quality primary care.

One large US study found that the availability of primary care physicians was consistently related to health levels on a variety of parameters, including overall mortality, cancer and cardiac mortality, neonatal deaths and life expectancy. In other words, the higher the primary care physician-to-population ratios in a US state, the better most health outcomes are. The findings persisted after controlling for confounding variables, such as poverty rates, education, rurality and lifestyle factors.

The fact that the US, where self-referral to specialists is common, ranks poorly among other nations on several health indicators also supports this finding. On one measure, Australia ranked fifth behind Japan, Sweden, Canada and France, while the US came in second last at 12th. Other research supports the view that primary care delivers the greatest benefits to health, but importantly, it’s not just any old primary care we’re talking about.

Specifically, it means a service that’s the first port of call for preventive and most therapeutic care. ?It means having a strong relationship with that doctor ? and providing care for all needs that are common in the population and referring to specialists when the problem is too unusual or uncommon for the primary care practitioner to manage,? Dr Starfield says, adding that it means co-ordinating care when necessary.

It seems in the search for a healthier community, we’re asking the wrong questions when we look for the best specialist or the hospital with the shortest waiting list.

Instead, we – politicians, the medical profession and the community – should be asking how we can ensure well-resourced, integrated, high-quality primary care.

This is an edited version of an article that appeared in Australian Doctor, a weekly newspaper for GPs.

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