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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.

Resumo Os pilares Starfield são revistos assim como o sistema de saúde canadense. Avaliação objetiva e subjetiva são aplicadas ao sistema sob as lentes do acesso, longitudinalidade, integralidade e coordenação de cuidados. Discutem-se as vulnerabilidades do sistema e as ações e propostas que estão em curso para tentar melhorar esses aspectos, tanto nacionalmente como na província de Ontário. Destaque para a oportunidade de se criar um sistema gratuito de medicamentos e os diversos desafios para avançar a agenda de reformas. Abstract This paper reviews the Starfield pillars and the Canadian health system. An objective and subjective evaluation are applied to the system through the lenses of access, longitudinality, integrality, and coordination of care. System vulnerabilities, actions, and proposals that are underway to improve these aspects, both nationally and in the province of Ontario, are discussed. Worth highlighting is the opportunity to establish a national free drug system, and the several challenges to advance the agenda of reforms.

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.

Amidst a pandemic that has acutely highlighted longstanding failings of the US health care system and the graduate medical education (GME) enterprise that serves it, educators prepare to embark on another revision of the program requirements for family medicine GME. We propose in this article a conceptual framework to guide this endeavor, built on a foundation of the core functions that Barbara Starfield suggested might explain primary care’s salutary effects. We first revisit these “4C’s”—first Contact, Continuity, Comprehensiveness, and Coordination—and how they might inform design thinking in primary care GME guideline revision. We also propose the addition of Community engagement, patient-Centeredness, and Complexity. Training residents to deliver on these “7C’s,” functions critical to the delivery of high-performing primary care, is essential if family medicine residency graduates are to serve the clearly articulated, but unrealized, quadruple aim for US health care: improved patient experience and population health at lower costs while preserving clinician well-being. Finally, we highlight and illustrate examples of four critical enablers of these 7C core functions of primary care that must be accommodated in training guidelines and reform, suggesting a need for resident competencies in Team-based, Tool- and Technology-enabled, Tailored (“4T’s”) care of patients and populations.

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.

The second Starfield Summit was held in Portland, Oregon, in April 2017. The Summit addressed the role of primary care in advancing health equity by focusing on 4 key domains: social determinants of health in primary care, vulnerable populations, economics and policy, and social accountability. Invited participants represented an interdisciplinary group of primary care clinicians, researchers, educators, policymakers, community leaders, and trainees. The Pisacano Leadership Foundation was one of the Summit sponsors and held its annual leadership symposium in conjunction with the Summit, enabling several Pisacano Scholars to attend the Summit. After the Summit, a small group of current and former Pisacano Scholars formed a writing group to highlight key themes and implications for action discussed at the Summit. The Summit resonated as a call to action for primary care to move beyond identifying existing health inequities and toward the development of interventions that advance health equity, through education, research, and enhanced community partnerships. In doing so, the Summit aimed to build on the foundational work of Dr. Starfield, challenging us to explore the significant role of primary care in truly achieving health equity.

Resumo Este estudo propõe a realização de uma revisão integrativa da literatura a partir de artigos e publicações sobre o uso do “Primary Care Assessment Tool (PCAT)” como instrumento de avaliação desses serviços, discutindo os resultados encontrados no Brasil e em outros países do mundo, a partir da matriz inicial concebida pela equipe da Professora Bárbara Starfield e propor atualizações para a versão brasileira. Identificaram-se 124 trabalhos; porém, após a leitura dos mesmos, foram selecionados 42, de acordo com os critérios de inclusão estabelecidos. Deste subtotal, 17 (40,5%) foram estudos brasileiros. Sugere-se a necessidade da atualização de itens de cada atributo do instrumento, em particular do “acesso – primeiro contato”, incluindo novas formas de comunicação médico-paciente como: e-mail, mensagens por aplicativos em dispositivos móveis, uso de software de transmissão de vídeo para comunicação e mesmo utilização de telemedicina, entre outros. O PCAT apresenta simplicidade quanto ao uso, aplicação e cálculo dos escores, o que o torna útil e adequado para uso na gestão local dos serviços, especialmente em suas versões reduzidas em número de itens. Abstract This study proposes an integrative review of the literature based on articles and publications on the use of the Primary Care Assessment Tool (PCAT) as a tool for evaluating these services, discussing the results found in Brazil and in other countries of the world, from the initial matrix conceived by Professor Barbara Starfield’s team and proposing updates for the Brazilian version. We identified 124 studies, of which 42 were selected after full reading and according to the established inclusion criteria. Of this subtotal, 17 (40.5%) were Brazilian studies. There is a need to update items of each tool’s attribute, in particular “access – first contact”, including new forms of doctor-patient communication such as: email, mobile application messages, use of videoconference software for communication and even use of telemedicine, among others. PCAT’s use, application and calculation of scores is simple, which makes it useful and suitable for use in the local management of services, especially in its short version.

The present article aims at discussing the singularities of primary health care (PHC) in contexts where violence, strongly supported by guns, is routinely, chronically, and systemically present, and to gauge the capacity of PHC as empowerment channel for communities where armed violence is an expressive vulnerability. Based on the Declaration of Alma-Ata and on the PHC principles described by Barbara Starfield, and focusing on community participation and social determinants of health, the discussion departs from the realities observed in Latin America and the commitment to access and universal coverage set forth in the third Sustainable Development Goal. The qualitative and quantitative characterization of armed violence and its consequences must be qualified using an intersectoral approach with heavy community participation in search of coherent and significant responses. The protection and safety of health care workers must be ensured to guarantee the continuous provision of health care services in contexts of violence.En el artículo se trata de abordar los aspectos singulares del trabajo de atención primaria de salud (APS) en los entornos donde la violencia, con el sólido apoyo del uso de armas de fuego, tiene una expresión habitual, crónica y generalizada, y de determinar la posibilidad que ofrece la APS de servir de canal de empoderamiento de la comunidad, donde la violencia armada representa una vulnerabilidad manifiesta. Con base en la Declaración de Alma-Ata y en los principios de la APS descritos por Bárbara Starfield, y con un enfoque en la participación comunitaria y en la perspectiva de los determinantes sociales de la salud, el debate tiene como punto de partida las realidades observadas en los países de América Latina y los compromisos orientados hacia el acceso universal a la salud y la cobertura universal de salud previstos en el tercero de los Objetivos de Desarrollo Sostenible. La caracterización cualitativa y cuantitativa de la violencia armada y de sus consecuencias debe hacerse a partir de un enfoque intersectorial con amplia participación comunitaria en la búsqueda de respuestas coherentes y significativas. También es preciso garantizar la protección y la seguridad de los profesionales para poder prestar servicios de salud de una manera continua en estos entornos.

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 inaugural Starfield Summit was hosted in April 2016 by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care with additional partners and sponsors, including the Pisacano Leadership Foundation (PLF). The Summit addressed critical topics in primary care and health care delivery, including payment, measurement, and team-based care. Invited participants included an interdisciplinary group of pediatricians, family physicians, internists, behaviorists, trainees, researchers, and advocates. Among the family physicians invited were both current and past PLF (Pisacano) scholars. After the Summit, a small group of current and past Pisacano scholars formed a writing group to reflect on and summarize key lessons and conclusions from the Summit. A Summit participant's statement, "a paradox persists when the paradigm is wrong," became a repeated theme regarding the paradox of primary care within the context of the health care system in the United States. The Summit energized participants to renew their commitment to Dr. Starfield's 4 C's of Primary Care (first contact access, continuity, comprehensiveness, and care coordination) and to the Quadruple Aim (quality, value, and patient and physician satisfaction) and to continue to explore how primary care can best shape the future of the nation's health care system.

O Estado como provedor do bem público busca disseminar a saúde entre seus habitantes, sendo uma das principais formas de realizar isso é através da Atenção Primária à Saúde. Esse contexto contribuiu para o escopo deste artigo, cujo objetivo é verificar a eficiência técnica da Atenção Primária à Saúde no âmbito do sudeste brasileiro. Com uma abordagem teórica, tomou-se como base a literatura nacional e internacional sobre o tema, com autores como Mendes, Starfield, Ozcan e Salinas-Jiménez. Para o cumprimento de tal objetivo, utilizou-se uma abordagem quantitativa, através do modelo de Análise Envoltória de Dados (DEA). Os resultados apontaram para escores de eficiência técnica baixos, considerando os inputs e outputs selecionados para a região. O que oferece indícios de eficiência relativa baixa e por consequência, são importantes intervenções e ações pró-ativas na gestão da atenção primária à saúde. The state as provider of public health seeks to disseminate between its inhabitants, one of the main ways to realize this is through Primary Health Care This scenario contributed to scope of this paper, whose purpose is to verify technical efficiency of Primary Health in the Brazilian southeast. With a theoretical approach, was consulted authors such as Mendes, Starfield, Ozcan and Salinas-Jiménez. For compliance of this objective, employed a quantitative approach, using the model of Data envelopment analysis (DEA). Results showed low technique efficiency scores, considering the inputs and outputs selected for the region. What provides signs of relatively low efficiency and consequently are important interventions and proactive actions in the management of primary health care.

In her landmark Lancet article ‘Is primary care essential?’1 Barbara Starfield described primary health care as being first-contact care that is comprehensive, coordinated, and continuous. To this could be added something about accessibility and effectiveness and, in the UK context at least, care that is provided locally and personally. In these changing times, most of these attributes of good primary care have come under pressure. Comprehensiveness can be threatened by inequalities in access, fragmentation of primary care teams, discrimination, and the effects of the inverse care law.2 Continuity is increasingly difficult to deliver, for well-rehearsed reasons, and coordination is often more of an aspiration than an achievement because of dysfunctional communication across the primary–secondary care interface. Finally, access, a crucial dimension of primary care, has become a political and professional battlefield in recent years. In last month’s issue of the BJGP Simpson and colleagues3 called for a policy rethink on access, and for a more nuanced debate to take us beyond the simple metrics of waiting times and capacity. This month, Access to Care is the major theme of the journal, with articles on the research evidence related to access,4 the controversy about 7-day NHS opening,5 and the persistent, pernicious influences of deprivation on equity and equality.6 The need for a more sophisticated discussion of access is emphasised by Campbell and Salisbury’s Research Into Practice article,4 in which they review the evidence on new opportunities to measure and improve access, as well as providing a useful model of the various factors and forces at play. Their careful review serves to show that the evidence base for much organisational thinking and policy rhetoric is based on very thin evidence or no evidence at all, although it is clear that good ideas may work well …

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?

Building continuity of care takes work but earns trust Estimates of the prevalence of multimorbidity vary according to how it is measured, but studies agree that prevalence is rising and that it increases precipitously with age.1 By middle age, multimorbidity is the new normal. The first article in this editorial series on multimorbidity highlighted the difficulty of achieving evidence based targets for multiple diseases in a single patient.2 Treating all of a patient’s diseases optimally represents a considerable management burden for the patient and can result in a chaotic experience of care. Barbara Starfield defined relational continuity in primary care as person focused care over time, and such an approach is needed for patients with multimorbidity, rather than the more traditional one of managing diseases.3 But how can continuity of care be achieved for patients with multimorbidity? Continuity of care is most commonly defined as a connected and coherent series of healthcare events, or seamless care.4 For the healthcare professional, this means having all the necessary information about the patient at the point of care (informational continuity) and coordinating actions with other providers to deliver services in a complementary and timely manner along a recommended care pathway (management continuity). Connectedness matters for healthcare professionals because it translates into technical quality of …

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 …

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.