Primary health care and family medicine at the core of health care: challenges and priorities in how to further strengthen their potential

This paper analyses the paradigm shift from the disease to the person with the disease against the background of the changes of health systems toward primary health care. The structural changes from hospital to the community and the specialist to the generalist approach are essential to enable this different approach. As a consequence, any assessment of health status, risks, and needs starts with an engagement with an individual. This engagement is the basis from which diagnostic, preventive, and therapeutic interventions are planned, over time, in the continuous working relation primary health care entertains with individuals and populations. Key to the functioning of primary health care is an ongoing renewal or actualization of this working relation, in this paper referred to as the “initial estimate,” that makes it possible to direct resources to those in highest need and at the same time makes it possible to exempt from costly and risky interventions those who have little to gain from it. This “initial estimate” is a major determinant of cost-effective and efficient healthcare, but there is hardly any insight into the process of how professionals in primary health care come to estimate individuals’ risk. This in turn presents a number of challenges and priorities for primary health care research: to build the interaction between practice and researchers in designing and developing tests; secure primary health care research capacity to study and assess tests in the primary health care setting; and secure the implementation of validated tests in routine patient care. to open to research the full setting in which patient and professional interact and integrate in this the contribution of diagnostic tests; to study professionals’ decision making, including the role of “experience” and “intuition,” mechanisms through which the premonition of something being wrong is coming about and to develop methods to train professionals to apply this in an appropriate way; to use these insights to study as well the effectiveness of preventive and therapeutic interventions; as the setting in which professionals operate influences the outcome of their performance, make sure that “every” community is connected to the primary health care research capacity. Introduction Many countries in the world live through a transition of their health care systems toward primary health care. In this, the care of patients is to be led from the community rather than the hospital, by a generalist rather than a specialist. This is in itself a fundamental change – a change in the structure of the health care system, in the conditions and facilities under which it operates and professionals and patients engage. This asks for new structures and models and their implementation is complex in its own right. The development of the concept of “the patient-centered medical home” in the US (1) is a good example of creating approaches that were impossible under the prevailing system. But there is a realistic danger that the transition toward a primary health care structure is seen as just this: replacing the hospital by the community, or the specialist by the generalist, with magical implications attached to this structural solution. Belief in “structural” change, with the generalist-family physician as a super human is often an implicit ingredient of healthcare reform. In this, primary health care continues to operate in the traditions of medicine, with diagnosis and disease as its determining currencies. The orientation on the person is an appreciated and valued add-on with the patient defined to no longer a single disease, but a set of co-existing health problems. But it is highly unlikely that generalists are able to deliver what specialists cannot, only because they practice in another location or there is “family physician” written on their front door. What is essential in the transition of health systems is to secure a different approach, from diseases to individuals with the diseases and populations at risk of the diseases. To be able to achieve this, health care has to be embedded in the environment in which people live and work, run the risk of illness and disease. The health system structural changes are essential exactly because they make a different approach possible, a paradigm shift from the disease to the person with the disease. And this paradigm shift is the pivotal point in reforming health systems. The challenges of primary health care are to capitalize on the working relation it has over time with individuals, families, and communities, in identifying, preventing, and managing health problems. This is the overarching context of continuity and integration of care to provide effective, efficient, safe, and timely health care. However, in the many pressing primary health care research needs, it is an undervalued aspect. This paper explores the challenges of research to support the successful completion of health care reform as a “structure and paradigm shift.” As will be made clear, the experience of seasoned practitioners in the field may well hold the key and research has to be directed to the systematic exploration of this experience, to create the knowledge that is needed to guide the success of how primary health care, how family physicians, can lead the system.