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Priorities of patients should not be overpowered by economic and political incentives
Primary care has an important part to play within healthcare systems.1 The World Health Organization defines the main aim of healthcare systems as the improvement of health, but it notes that financing should be fair and systems of care ought to respond to people's expectations.2 Countries whose healthcare delivery focuses on the role of the specialist tend to fare less well in surveys that take account of these three goals.3 Primary care seems to offer important advantages within healthcare systems in terms of cost containment, health status of the population, and a range of other health related outcomes—the value of a strong primary care base within national healthcare systems is recognised by the WHO.4 How can cross national studies provide insight into the optimal organisation of health care?
In this week's BMJ, Bindman and colleagues5 use data from national surveys in Australia, New Zealand, and the United States to compare mix of patients, scope of practice, and duration of visits in primary care. Previous studies have compared patient morbidity and patients' expectations of care between countries.6 7 This study differs in that it examines case mix and exposure to primary care in three countries using rigorous and innovative ways to analyse large nationally representative datasets.
In primary care, length of consultation has been proposed as a marker of quality of care, with longer consultations increasing patients' satisfaction and being more comprehensive and more responsive to patients' needs.8 9 Few studies have reported exposure to primary care in populations or have used such a measure to investigate differences between groups of individuals with regard to the experience or outcome of health care.
In the United Kingdom, a recent national survey of primary care provision10 reported a median consultation length of 13.3 minutes for general practitioners in 2003. UK patients have an average of 4.5 consultations each year, so these figures imply a per capita annual exposure to primary care physicians of around 60 minutes each year—an increase of 28% in just five years.11 Bindman and colleagues highlight a substantial variation in such exposure between the three countries they studied—from 29.7 minutes each year in the US to 83.4 minutes each year in Australia.
Similar methods to those used by Bindman and colleagues to define case mix have been used to investigate the relative contribution of social class and case mix in modelling the use of home visits in primary care settings.12 The methodological approach used in the current study to assess differences in case mix is sophisticated; it draws on a diagnostic coding system developed at Johns Hopkins Hospital, which has been validated for use in primary care. It has the potential to compare case mix in primary care in countries that extensively use morbidity coding systems, such as those of the International Classification of Disease or READ coding system.
A limitation of Bindman and colleagues' study is that only administrative or preventive care codes were recorded in up to 20% of consultations, and these were excluded from the analysis. While the role that doctors play in society varies in different countries, the authors are right to note that such consultations should be included in the overall assessment of case mix. This would enhance the generalisability of the findings and provide a more comprehensive overview of the contribution of primary care to the healthcare system within the country.
It may be surprising to general clinicians providing “comprehensive” first line care that 75% of the workload of US primary care physicians' comprises just 46 conditions. Also, this number rose to only 57 conditions for family doctors in New Zealand, a country that is much more orientated towards primary care than the US, and which has healthcare structures similar to those of the UK National Health Service. Some substantial differences were seen between national populations in primary care case mix—women in the US had lower rates of attending primary care for gynaecological problems, but attendance for endocrine and cardiovascular problems was much higher in the US than in Australia and New Zealand. Such observations may reflect differences between countries in access to care and in the gatekeeping role of family doctors, but they may also result from cultural differences between populations in their interpretation of symptoms and in their use of health services.
Even in Western healthcare systems, inequalities in health status and experience of care exist between individuals. Squandering of resources through failure to provide a strong primary care base within national health systems is likely to reinforce divisions within society, worsen the health status of individuals, and create a healthcare system that is unresponsive to the needs of the population. Cross national comparative studies have the potential to inform the development of services, but they need to take account of the beliefs and values of the people served as well as the ambitions and resources of their health professionals and politicians.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.