Primary care models - Let a hundred flowers bloom

Abstract

The contrast between the eventualities of the 1985 Scott Report and the 1990 Working Party on Primary Health Care Report could not have been more stark. The World Health Organisation reminded member states, through the 2008 World Health Report Primary care: now more than ever, to put into action what had been declared in Alma Ata 30 years ago. Twenty years after the Working Party report, the Government finally set out more concrete directions for primary care development in a 2010 Strategy Document. The time has come to execute those ideals and to turn rhetoric into reality. An evolutionary, evaluative approach that recognises real politik would be preferred over a system-wide revolution. The various pilot schemes involving direct provision/subvention (in the form of community health centres), outsourcing (whether wholesale as in the Tin Shui Wai model or by disease condition as for hypertension and diabetes) and vouchers (elderly and vaccine programmes) could be expanded to experiment with other different models of service delivery. These may include the American “medical home”, Australia’s medicare locals, Britain’s general practice with commissioning responsibilities or the Ontario blended family health models, amongst other innovative forms. An equally important priority would be to understand and work with the contextual circumstances of existing primary care providers. The politico-economic ecology of private ambulatory care, which provides 80% of services, has undergone substantial changes recently that need to be accounted for when planning reform. Primary care reform should no longer remain an afterthought or at best paid lip service. It should be allowed to experiment, be evaluated and implemented – now more than ever.