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Rethinking primary care

November 11, 2013
 Martin Marshall Prof Martin Marshall, Lead, Improvement Science London

Most people are inclined to what we might call a ‘provider bias’ when asked to describe how health care is organised and delivered. Familiar structures are embedded in our psyche – primary care, where generalist first-contact services are provided close to people’s homes; secondary care, where a wide range of specialist services are provided in general hospitals; and tertiary care, where a narrow range of services are provided in super-specialist hospitals. If the concept of ‘self-care’ gets any look-in, it is usually as an after-thought and rarely with much conviction.

But this neat world is being challenged, and not just because we are blurring the boundaries between traditional sectors. If the formal institutions making up the NHS are to survive in any form, we need to put greater emphasis on the informal systems that underpin them. At a recent seminar I heard Stewart Bell, Chief Executive of Oxford Health NHS Foundation Trust, one of the most experienced managers in the NHS and champion of things unfashionable, suggesting a radical change in terminology. How about this: Primary care is what people do for themselves to improve their health, like taking paracetamol when they have a headache or looking after their diabetes. Secondary care is what families, friends and members of the local community do for people when they are unwell, like providing a listening ear when someone is stressed, or reminding others to give up smoking and eat healthily. Tertiary care is what general practitioners, community-based nurses and other community practitioners provide for patients when they decide to utilise formal care. Quaternary care is what goes on in hospitals and quinary care is what happens in super-specialist hospitals.

Is this just playing with words? I don’t think so. Language is a product of the way that we think but also influences how we conceptualise what we see around us. It is strange that we seem to be more willing to restructure our buildings than we are to restructure our thinking but doing the latter might be more beneficial than the former. The interface between community and hospital services is important but the one between self-care and professionalised care has the potential to offer far more opportunities to improve the experiences, outcomes and value of care. This is the space in which people manage self-limiting conditions without recourse to expensive and sometimes damaging medical interventions, where people with long term conditions realise the evidence-based benefits of working as active partners with health professionals, rather than as grateful recipients of professional largess. Re-defining what we mean by ‘primary care’ puts patients first and raises the profile of self-care and shared-care in the consciousness of the health system.

The formal health system is important but in the greater scheme of things, not as important as it thinks it is. And it might have a greater impact on people’s health if it focused its considerable resources on helping people to deliver their own primary and secondary care.

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