July 14, 2016

The Minister of Health and Long-Term Care, Dr. Eric Hoskins, is undertaking a large scale restructuring of Ontario’s primary health and community care service systems. In recent documents and in media stories covering these planned changes, there has been repeated reference to primary care without a clear definition of what primary care is.  In addition, they tend to bundle hospital care in with primary care services, which alters the make-up and focus of the primary care system.

To fill this vacuum Care Watch is attempting to describe primary care to ensure that we can agree on what we are likely to be getting in a restructured system.

Defining primary care through the literature is slippery, because there does not appear to be a single, universal definition.  However, a review of Canadian definitions leads us to three concepts:

1. Primary care involves basic health care or services, as seen in the following definitions:

• Health care at a basic rather than specialized level for people making an initial approach to a family physician, nurse practitioner/nurse, pharmacists, midwife or others for assessment or treatment
• Primary Care is the first level of care or, and usually, the first point of contact that people have with the health care system. (FPT Vision 2000)
• “A service at the entrance to the health care system” (Canadian Patient Safety Institute and the BC Patient Safety and Quality Council.)

2. Primary care involves an inclusive basket of services focusing on health promotion, illness prevention and the maintenance of health, such as:

• Routine care (often called “well-person” visits for health maintenance purposes)
• Care for urgent, but minor health problems (e.g., colds/ flu, stomach problems, muscle strains, minor cuts and scrapes, etc.)
• Maternity and child care (e.g., pre-natal care, midwifery, well-baby visits, vaccinations, etc.)
• Chronic care (i.e., management of chronic diseases or conditions, such as diabetes, arthritis or other pain, which affect activities of daily living)
• Psycho-social services, including mental health care
• Health promotion (e.g., smoking cessation, etc.) and disease prevention (e.g., vaccinations)
• Nutrition counseling, including weight management
• End of life care (CIHI)
• Liaison with other health service providers, such as home and community care, hospital-based specialists, etc.

3. Primary care considers and acts on non-medical factors in providing services:

• Primary care is delivered by a range of health professionals, including family practitioners, nurses, dietitians, patient educators, occupational therapists, community pharmacists, etc.
• Primary care is delivered at the local neighbourhood or community level, rather than at a regional level
• Primary care tends to consider the social determinants of health in providing services

System-related issues, such as integrating, planning and expanding health services, and developing policy regarding service delivery have a significant impact on primary health services. 

In our review of recent policy statements, newspaper articles and announcements there has been repeated reference to hospital care as part of the basket of primary care services.  Care Watch rejects the inclusion of hospital services in primary care. 

Historically, hospitals are “secondary” and “tertiary” facilities for intensive and advanced medical care provided by specialist (medical, dental, mental health and other health therapists), designed to investigate, diagnose and treat serious and urgent illnesses, injury, disease or other health conditions, and requires more specialized knowledge, skill and/or equipment than can be provided at the local level. Access to hospital services generally requires referral from a primary care physician, except in the case of emergency services for medical crises or trauma. However, emergency departments are not generally the first contact with patients who are not experiencing a medical crisis or trauma. 

Secondary care involves specialists who tend to focus on specific body systems, for example, the heart or its pumping system (cardiologists); our hormone systems (endocrinologists); or specific diseases or conditions, such as, chronic diseases like diabetes or arthritis (rheumatologists), and cancers (oncologists).

Secondary care includes acute care, which is necessary, but short-term medical treatment for serious illnesses, injuries or other health conditions. Acute care also includes skilled medical and nursing services during childbirth (e.g., high-risk deliveries, caesarian surgery, and neo-natal care); intensive care, which is concerned with the diagnosis and management of life-threatening conditions requiring sophisticated physiological support and invasive monitoring, and medical imaging (e.g., CT and MRI scans) for diagnostic purposes. Emergency departments provide acute care services for medical crises or trauma. Unfortunately, because of the lack of accessible alternative services, an increasing number of people, such as seniors and the homeless, are relying on emergency departments for primary care services.

Tertiary care requires highly specialized equipment and expertise, such as coronary artery by-pass or transplant surgery, renal or hemodialysis, some plastic surgeries or neurosurgeries, severe burn treatments or any other very complex treatments or procedures.

Care Watch’s view – and that of many other institutions and organizations worldwide – is that primary care is community-based, not hospital-based.  Whereas some services may be provided in hospital – by virtue of the fact that there is an absence of appropriate providers in some communities and neighbourhoods – Care Watch believes that hospitals are not the most appropriate site of delivery of primary health care is in the community. 

Care Watch disagrees with attempts to designate hospitals as lead agencies for home and community care coordination and advocates that multi-disciplinary primary health and community care agencies, that are funded appropriately, assume local service coordination responsibilities.

Hospital services must be effectively linked to and coordinated with primary care services and, to the extent that Bill 210 achieves this, it is to be welcomed.  But to simply bundle hospitals into primary care will dilute their focus and expertise, overly medicalize health and misspend scare pubic resources.