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Pharmacists are more often being recognized as a critical component of the primary care team. Previous literature has not clearly made the connection to how pharmacists and comprehensive medication management (CMM) contribute to recognized foundational elements of primary care. In this reflection, we examine how the delivery of CMM both supports and aligns with Starfield's 4 Cs of Primary Care. We illustrate how the delivery of CMM supports first contact through increased provider access, continuity through empanelment, comprehensiveness by addressing unmet medication needs, and coordination through collaborating with the primary care team and broader team. The provision of CMM addresses critical unmet medication-related needs in primary care and is aligned with the foundational elements of primary care.

The training family medicine residents receive will have a lasting impact on how they deliver care in the future. Evidence demonstrates an imprinting effect based on the training environment itself. Thus, residency training represents a critical time for establishing clinical experiences that embody core primary care principles and ensure excellent care delivery. This paper focuses on the clinical experience in the family medicine practice setting. We have used Starfield’s four C’s of primary care and added two more: cost and community, as the tools to achieve the triple aim. In reviewing the current state of residency programs across the country, we noted that there was a lack of measurement on how programs were performing when it came to the six C’s. We will briefly describe some recent innovative collaboratives among residencies. Next, we examine the six C’s of primary care in context of current care. These six C’s inform our recommendations for residency training standards to create the family physicians of the future. The overarching theme of these recommendations is the need to measure and report on what we want to ultimately improve.

The primary care network (PCN) was implemented as a healthcare delivery model which organises private general practitioners (GPs) into groups and furnished with a certain level of resources for chronic disease management. A secondary qualitative analysis was conducted with data from an earlier study exploring facilitators and barriers GPs enrolled in PCN’s face in chronic disease management. The objective of this study is to map features of PCN to Starfield’s “4Cs” framework. The “4Cs” of primary care—comprehensiveness, first contact access, coordination and continuity—offer high-quality design options for chronic disease management. Interview transcripts of GPs (n = 30) from the original study were purposefully selected. Provision of ancillary services, manpower, a chronic disease registry and extended operating hours of GP practices demonstrated PCN’s empowering features that fulfil the “4Cs”. On the contrary, operational challenges such as the lack of an integrated electronic medical record and disproportionate GP payment structures limit PCNs from maximising the “4Cs”. However, the enabling features mentioned above outweighs the shortfalls in all important aspects of delivering optimal chronic disease care. Therefore, even though PCN is in its early stage of development, it has shown to be well poised to steer GPs towards enhanced chronic disease management. Ministry of Health (MOH) National Medical Research Council (NMRC) Published version This study was funded by two grants. The National Medical Research Council (NMRC) and Ministry of Health (MOH), Singapore, Health Service Research Grant (HSRG) (Funding Number: NMRC/HSRG/0086/2018) and the Centre Grant Programme Singapore Population Health Improvement Center (Funding Number: NMRC/CG/C026/2017_NUHS).

Several middle and upper income countries carry out household surveys that seek to trace the profile of access and use of health services. Probably one of the most ambitious examples is Brazil, with its National Health Survey (PNS-2019). We evaluated PNS-2019, presenting in an unprecedented way, one of its innovations, which refer to Starfield and Shi's adult Primary Care Assessment Tool (PCAT).Based on a cross-sectional study, we evaluated Module H of the PNS-2019, which interviewed a probabilistic sample of about 10,000 adults in 2019 in all 27 Brazilian states. According to the PCAT methodology, an average score equal to or above 6.6 indicates a greater orientation and quality of the evaluated primary care services.Brazilian overall PCAT score [5, 9] reveals the need to improve primary health care services across the country. There were no statistically significant differences in the scores by sex (men and women, 5.9), and race (whites 5.9 [5.7; 6.0] and brown / black 5.9 [5.8; 6.0]). On the other hand, there was a difference in terms of age. The elderly evaluated the services in a more positive way (score = 6.1 [6.0; 6.2]), when compared to those aged 40-59 years (5.9 [5.7; 6.0]) and 18 to 39 years (5.6 [5.5; 5.8]). First results of PNS-2019 show that the population that most needs primary care services in SUS is the one with the best perception and the most positive evaluation of the actions and procedures offered in health facilities.During 2019, Brazil undertook important structural reforms in PHC based on a new financing model with the aim of inducing an improvement in efficiency and strengthening its attributes. It is essential that countries with universal health coverage (UHC) guarantee access to their population and, especially, the most vulnerable, seek better efficiency of these services and regularly assess PHC based on the population's perception, through an independent methodology that monitor the quality of services and the strength of PHC, generating value for public resources applied to health services.INTRODUçãO: Vários países de renda média e alta realizam pesquisas domiciliares que procuram traçar o perfil de acesso e uso dos serviços de saúde. Provavelmente um dos exemplos mais ambiciosos é o Brasil, com sua PNS. Avaliamos esse inquérito e apresentamos, de forma inédita uma de suas inovações, que se refere ao uso do instrumento Primary Care Assessment Tool (PCAT). MéTODOS: Com base em um estudo transversal, avaliamos o Módulo H da PNS-2019, que entrevistou uma amostra probabilística de cerca de 10.000 adultos em 2019 em todos os 27 estados brasileiros. De acordo com a metodologia do PCAT, um escore médio igual ou acima de 6,6 indica uma maior orientação e qualidade dos serviços de atenção primária avaliados.O escore médio geral do PCAT no Brasil foi de 5,9, revelando a necessidade de melhoria dos serviços de atenção primária à saúde em todo o país. Não houve diferenças estatisticamente significantes nos escores por sexo (homens e mulheres, 5,9) e raça (brancos 5,9 [5,7; 6,0] e pardos / pretos 5,9 [5,8; 6,0]). Por outro lado, houve diferença em termos de idade. Os idosos avaliaram os serviços de forma mais positiva (escore = 6,1 [6,0; 6,2]), quando comparados aos de 40–59 anos (5,9 [5,7; 6,0]) e 18 a 39 anos (5,6 [5,5; 5,8]). Os primeiros resultados da PNS-2019 mostram que a população que mais necessita dos serviços de atenção básica no SUS é aquela que tem melhor percepção e avaliação mais positiva das ações e procedimentos oferecidos nas unidades de saúde. DISCUSSãO: Durante o ano de 2019, o Brasil fez reformas estruturais importantes na APS a partir de um novo modelo de financiamento, com o objetivo de induzir uma melhoria da eficiência e fortalecer seus atributos. É fundamental que países com sistemas de saúde de cobertura universal, garantam acesso a sua população e, em especial, aos mais vulneráveis; busquem melhor eficiência desses serviços e avaliem regularmente a APS a partir da percepção da população, por meio de uma metodologia independente que monitore a qualidade dos serviços e a força da APS, gerando valor aos recursos públicos aplicados nos serviços de saúde.

In this BJGP Open collection, we examine how international primary care systems have performed in response to COVID-19. The past few months have seen rapid change and adaption of primary care systems to meet unprecedented new challenges. The pandemic has also exposed critical weaknesses in systems all over the world.1 The World Health Organization (WHO) and the World Organization of Family Doctors (WONCA) contend that an ideal primary care system should fulfil the core characteristics laid out by Barbara Starfield:2 primary care should be accessible, affordable, available at the time of need, and represent the ‘front-door’ to the health system. It should provide ongoing care and coordination with other specialists and focus on individuals and their families beyond their biological disease.3,4 The Astana Declaration5 and the WHO Vision for Primary Health Care in the 21st Century 6 also make a case for empanelment (working for a listed or geographically defined population) and a model of primary care that is engaged with …

The core function of medical schools is to produce the doctors the nation needs1 and the NHS is clear that it now needs 50% of medical students to choose training for general practice. However, only 16.4% of newly qualified British-trained doctors seek postgraduate GP training.2 Moreover, one-third of British-trained doctors thought that their medical schools had not put them in a position to assess a career in general practice.3 I have met several junior doctors who have not heard of, let alone read, the writings of Professors McWhinney4 and Starfield,5 two world-class thinkers about general practice. GPs without understanding of the principles of their role have a shallower vision and often lower job satisfaction. How has this happened? When the NHS was established in 1948 many arrangements were made with the medical schools at a time when general practice was not a discipline and there was no professor of general practice in the world. The medical schools were initially entirely specialist led, linked to tertiary specialist hospitals with many special privileges. Training specialists was the priority and leading specialists, like Lord Moran, a Dean of St Mary’s Medical School, saw GPs as: ‘… having fallen off the ladder’.6 Professors of general practice came late to the party, first in Scotland in 1963, and in England in 1972. They were vigorously resisted by the Bristol, Cambridge, and Oxford medical schools, which appointed late in the 1990s. General practice/primary care struggled to gain entry to medical schools and even in 2017 …

Direct Primary Care (DPC), where patients pay a fee to a primary care provider to obtain access to services, is a delivery model that has received notable attention and enthusiasm from some providers. Proponents of DPC believe that the model increases accessibility, reduces overhead, and ultimately improves care for patients; however, there is little evidence in the peer-reviewed literature to support these claims. The objective of this analysis was to apply Starfield's adaptation of Donabedian's Structure-Process-Outcome conceptual model to evaluate primary care to formally display the links between potential changes in clinical structure and processes from DPC adoption. Based on existing literature on the constructs in Starfield's model, expectations of DPC's impact at the patient, clinic, and system levels were defined. DPC uses changes to financing and the population eligible to trigger potential gains in continuity and accessibility to subsequently improve care processes. There is evidence to support DPC as a theoretically sound approach to improve attributes of primary care, such as first contact care and longitudinality at the clinic level for participating patients. At the health system level, DPC has low-construct validity that would suggest a positive impact on the potentially eligible population's health due to membership fees that exclude patients who are more likely to be vulnerable and complex than patients who are willing and able to stay in the practice. Descriptive and comparative research of included and excluded patients is needed to inform providers, patients, and policy makers of the DPC's ability to attain the attributes of primary care and ultimately achieve better outcomes over alternative primary care delivery and financing models. Meanwhile, theoretic application informed by years of research on primary care provide insight as to what changes to expect and to monitor as practices consider DPC adoption.

The Starfield Summit crystallized key challenges and opportunities as primary care enters an era of value-based payment (VBP). New primary care models must reinforce Starfield’s core primary care functions while achieving the quadruple aim. Achieving these objectives requires pragmatic, rapid

Barbara Starfield and colleagues present evidence that having more primary care physicians and fewer specialists per capita is associated with lower mortality rates. These analyses stand ...

Barbara Starfield’s research showed that investing in primary healthcare is the way to a successful health system. So why are these lessons not being heeded, asks Michael Caley, and will general practice commissioning help?

More time and provision of innovative tools to coordinate care may help Patients with multimorbidity often need more frequent general practice consultations, and more complex and structured care, than those with a single condition. Their care is often shared and needs to be coordinated with specialist community and hospital teams. A recent article in this series drew attention to the importance of having one main coordinator of care for patients with multimorbidity,1 and Starfield and colleagues highlighted, almost a decade ago,2 the challenge that primary care practitioners face in managing patients with multimorbidity more effectively. The standard primary care consultation for patients with multiple conditions needs to change, but how? Multimorbidity influences the general practice consultation in three main ways. Firstly, the amount of clinical information that must be collected for an individual patient with many different conditions can be extensive, especially when conditions and their stability change over time.3 Secondly, as conditions progress over time, management priorities and consequently information gathering, plans, and coordination of care must change.4 Thirdly, communication with other services involved in …

The entry point for most people into any healthcare system is primary care. Not surprisingly, primary care–oriented disorders make up the vast majority of all medical conditions seen by healthcare providers. Starfield (1994) pointed out that countries whose health systems are oriented toward primary care achieve better health levels, higher satisfaction with health services among their populations, and lower expenditures in the overall delivery of health care. The American system relies heavily on both physicians as well as nonphysician clinicians to deliver primary care. In the US this cadre of providers includes doctors, PAs and nurse practitioners (NPs).

Barbara Starfield, perhaps the most influential figure in the primary care research community, died unexpectedly at home on June 10 this year while swimming in her pool. She was steadfast in her belief that primary care is central to the delivery of high quality cost-effective health care. Her second passion was as a champion of primary care as the key way to address healthcare inequalities, and she was founding editor of the International Journal for Equity in Health. She was highly critical of health care in her own country, (the US), viewing it as dominated by specialists who provide expensive, inequitable, and sometimes damaging …

I learned of Barbara Starfield’s sudden death from her husband, Neil “Tony” Holtzman. In his e-mail, sent at 2:43 am on Saturday, June, 11, 2011, Tony reported that Barbara’s absence from a simple act of nurturing, generosity, and generativity was the first sign that something was amiss—

We want to thank Dr. Barbara Starfield for her insightful commentary about our paper in CMAJ May 26. While we agree with the issues she raised, her article contains a misleading statement that the higher rate of visits to emergency departments in capitation was observed only in rural areas. This

A continuing patient–doctor relationship has achieved the status of a core value and feature of primary care.1 In this issue of the BJGP , two papers by Salisbury et al 2 and Ridd et al 3 add to the large body of primary care research seeking to improve the definition and measurement of the continuing patient–doctor relationship. The aim is to understand and defend it as a core feature. It has been under pressure as primary health care moves away from autonomous single-handed practices to multidisciplinary group practices with common accountability to central authority. For primary care and family medicine the continuing patient–doctor relationship has been subsumed under the broader concept of continuity of care.4 Clinicians from other health disciplines recognise the importance of the relationship with the patient but use the term ‘continuity of care’ to refer to the delivery of services in a coordinated and timely manner by more than one health professional. Salisbury and colleagues call this coordinated care, as would most primary care clinicians. Both Salisbury et al and Ridd et al use the label ‘longitudinal continuity’ to describe the primary care model of continuity of care, a tribute to Barbara Starfield who proposed this term to distinguish it from that of continuity of care used in other disciplines.5 Ridd et al synthesize what qualitative research tells us about the nature of the patient–doctor relationship, where the regularity of good experiences with the doctor over time leads …

To the Editor. —In their discussion of restructuring licensing policies, Starfield and Simpson1essentially state that the government or some other monitoring body should determine whether or not a physician in a given specialty is allowed to go into a practice within a specified area based on statistics of case mix and the like. It is unprecedented, un-American, and probably unconstitutional for the government to direct people where to live. There is no difficulty with the government using incentives to try to direct professionals to an area where it is felt they may be needed and away from areas where it is felt that they are not needed. To deny any American the right to live and attempt to practice their profession where they will is anathema and invalidates the entire program.

To the Editor. —Starfield and Simpson 1 outline some important steps for bolstering the role of primary care physicians in health care reform. But one problem they don't address is that of medical bigotry. By this I mean the prejudice that exists at many of our medical institutions against the specialty of family practice. I single out family practice from the other primary care specialties of general internal medicine and pediatrics because by and large they don't face this problem. But ask just about any medical student interested in family practice, and I think the odds are that they've been subjected to pervasive negative propaganda from attending physicians in other specialties. I interview medical students from all over the country, and the tales they tell are all too familiar to me and my colleagues in family medicine. Here's a sample of what they hear: "Why would you want to go

To the Editor. —The 12-avenue approach of Starfield and Simpson 1 to upgrade primary care in US health services is innovative. Maldistribution of physicians still leads to a significant shortage of primary care physicians across the United States. The role of international medical graduates (IMGs) needs to be emphasized. Their numbers are almost equivalent to the the graduate output of approximately 17 US medical schools, with as many as 58% of these IMGs in 1988 alone being non-US citizens. 2 The bulk of them enter the United States on the exchange visitor's (J-1) program and receive their training at the expense of the United States for periods ranging from 3 to 5 years. They return to their home countries where they often find that their acquired expertise is inappropriate owing to lack of facilities and resources. Hence, the magnanimity of the United States and the well-intended purpose of the J-1

To the Editor. —Starfield and Simpson 1 are to be complimented on their recommendations for strengthening the provision of primary medical services in the United States. However, I would go further and suggest that access to specialist services, except in the case of an emergency, should be only by referral from a primary care provider. Under the reformed health service it would be feasible for everyone to have a primary care provider of record. Only this provider would be granted the discretion to refer a patient for specialist care. In Britain it is unethical for a specialist to see a patient without referral from a general practitioner; penalties could be imposed on specialists accepting patients without referral. This policy would achieve considerable economy by avoiding the costly duplication of services that now occurs and would permit each provider to practice the type of medicine he or she does best. A

Starfield and colleagues have suggested four overarching attributes of good primary care: "first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere." As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.

Elsewhere in this issue of the Journal, Drs. Fishbane and Starfield offer us some new data comparing the care of children given by general practitioners and by pediatricians in a number of ways.1 T...

Nurse practitioners are concerned with demonstrating quality of care. Of the three variables which compose quality assessment, the third variable, outcome, provides the most direct and appropriate way to judge the nurse practitioner's special health orientation. Most studies have judged nurse practitioners' care based on medical standards and criteria. Starfield's conceptual model of outcome measures is health oriented. This model is a multi-dimensional health profile with categories that incorporate a longitudinal approach to outcome assessment. It allows for identification and evaluation of nursing effectiveness in primary care.