Realising the Potential of Primary Health Care

Executive summary

Primary health care can save lives and money while levelling the playing field to achieve more equal access to medical treatment. Such positive outcomes materialise when primary health care is a primary source of care that addresses the majority of their patients’ needs, knows their medical history, and helps them to co-ordinate care with other health services as needed. While in most OECD countries primary health care has not yet realised this full potential, several initiatives already show the way forward.

Based on the most promising country experiences, the OECD report Realising the Potential of Primary Health Care finds that reconfiguring the delivery of primary health care with multi-professional teams, equipped with digital technology, and seamlessly integrated with specialised care services, could help doctors, nurses, pharmacists and community health workers to provide more effective care. Empowering patients and measuring how primary care services deliver results that truly make a difference to their lives are also key for the provision of high performing care. If anything, the COVID‑19 pandemic only makes these messages more relevant. Promising innovations in primary health care can boost the capacity of OECD health systems to contain and manage future health crisis and reduce unnecessary hospitalisation of people that can be effectively treated in the community. In other words, a modern and efficient primary health care system serves as the cornerstone of resilient health systems.

Strong primary health care makes health systems more effective, efficient, and equitable

Interest in primary health care as a path for high performing health systems is not new. The 1978 Alma-Ata declaration recognised the critical importance of high-quality primary health care in the creation of effective and responsive health systems. Since then, the rising costs of medical care, increased citizen expectations from health systems, population ageing, and greater prevalence of chronic diseases have only reinforced the interest in the efficiency of primary health care.

With the share of the population aged 65 and above set to almost double to 28% by 2050, OECD countries must reconfigure their health systems to deliver more effective and high-quality care for people living for a long time with chronic conditions, while avoiding unnecessary use of hospital and specialised services. By providing the main point of contact for patients and especially for those with complex care needs, primary health care can make health systems more efficient, effective, and equitable across OECD countries.

Better, more accessible primary health care results in lower rates of hospitalisations and emergency department use. Primary health care can prevent unnecessary procedures and lower the need for the use of costly and scarce facilities, such as emergency rooms and hospitals.

Robust primary health care can delay the onset of chronic disease and reduce mortality rates. Its role in prevention, from encouraging people to stop smoking to early detection of breast and colon cancer, is critical to patients’ lives while quality primary health care is linked to higher patient satisfaction.

Solid primary health care is also associated with lower health inequalities. Across the OECD and EU, 67% of people in the lowest-income group have seen a General Practitioner (GP) in the past 12 months relative to 72% in the top income bracket, a gap of 5 percentage points. Inequalities across income groups are significantly more pronounced when it comes to seeing a specialist (12 percentage points gap), or to have received breast cancer screening (13 percentage points gap). Primary health care can ensure access to vulnerable populations that otherwise can struggle to access medical services.

Most health systems are still failing to reach the full potential of primary health care

So far, primary health care has not always been successful at keeping people out of hospitals. Across 30 OECD countries, hospitalisations for diabetes, asthma, chronic obstructive pulmonary disease, heart failures and hypertension alone – all of them largely avoidable through strong primary health care – correspond to 5.8% of all hospital bed-days. In 2016, these avoidable hospitalisations cost a total of USD 21.1 billion in this group of 30 countries.

Insufficient focus on prevention contributes to these results. Too many patients with chronic conditions still do not receive the recommended preventive care, especially the most vulnerable populations. One quarter of patients across 28 OECD and EU countries suffering with some chronic conditions did not receive any of the recommended preventive tests in the past 12 months.

In most countries, the share of doctors that work in general practice and the proportion of time general practitioners dedicate to preventive care is falling. On average, across OECD countries, generalists accounted for less than three out of ten physicians in 2017. In Australia, the United Kingdom, Denmark, Israel, Estonia and Ireland, the share of generalist medical practitioners decreased by more than 20% between 2000 and 2017.

Patients complain about a lack of communication and co-ordination between different parts of the health care system. In Norway, the United States, and Sweden more than 45% of patients experienced care co-ordination problems linked, for example, to test results, medical histories and receiving conflicting information, while in Germany it was just 29%.

New models of care, more economic incentives, and broader role to patients are needed

Across OECD countries, promising innovations in primary health care are taking place, and the evidence base on how to promote greater effectiveness is growing. However, most of these experiences are at the local level or have small scale, and they have not yet achieved the full potential for a system-wide transformation of care. The report highlights the following necessary changes:

• First, across the OECD, the future of primary health care will be in new models of care that are different from the single-practice physician, mostly responding to acute episodes of care, and working in isolation from a network of services. The most promising policy developments in OECD countries are the creation of new configurations of care, which house multiple professionals with advanced skills working in teams, supported by digital technology to enable seamless co-ordination of care, and that are pro-actively engaged in preventive care, tailored to the needs of the population they serve. New models of primary health care based on teams or networks of providers were reported by 17 OECD countries in 2018, including Australia, France, Switzerland, and the United States. Many of those models are focused on improving health care access of low-income or underserved populations, who face barriers to using traditional models of primary health care services, as well as patients with complex needs such as multiple chronic diseases.

• Second, more economic incentives are needed to encourage primary health care to work in teams and focus on prevention and continuity of care, especially for patients with chronic conditions, and close attention to care transitions co-ordination. Across OECD countries, policy innovations are taking place to provide better remuneration or economic incentives for the primary health care providers, based on their performance. In 2018, 11 OECD countries, including Israel, Mexico, and the United Kingdom, reported using specific add-on payments to incentivise care co-ordination, prevention activities or active management of chronic disease, and 15 countries, such as the Chile and Netherlands, reported using pay-for-performance mechanisms in primary health care.

• Third, the future of primary health care increasingly depends on giving a broader role to patients. In part, this includes involving the patients in the co-production of their health, through better support to self-management of their conditions and exposure to risk factors. Digital tools can play a significant role in this context. In Canada and Finland, for example, patient-provider portals are used to improve communication with primary health care providers to provide patients with access to their own health data and to relevant, curated, health-related information. Listening to the patients through the regular collection of experiences and outcomes of care will be increasingly needed as a tool to improve what matters to them the most. The Patient-Reported Indicators Surveys (PaRIS) launched by the OECD in 2017 will address the need to understand the outcomes and experiences of people with chronic diseases.

These messages are as important as ever in the light of the COVID‑19 pandemic which has, in many cases, accelerated the implementation of promising innovations in primary health care to achieve a system-wide transformation of care. Indeed, the coronavirus disease crisis has stimulated many innovative practices at national and local level, such as expanding the roles of nurses and pharmacists, developing digital solutions to monitor health status, ease access to care and using health information infrastructures for disease surveillance. Promoting the continuity of these practices and their wider adoption as health systems move into the pandemic recovery phase is critical for making health systems more resilient to health crisis.

Many of the lessons learned from primary health care experience in OECD countries and the main policy avenues for future developments apply to other contexts, including low- and middle-income countries. The report closes with a discussion of the primary health care landscape in low- and middle-income countries, and the key strategic approaches to ensure the continued development towards high-quality primary health care. Across the many countries where universal health coverage has not yet been achieved, investing in primary health care represents the most feasible roadmap to get there, and in the most affordable way.

Effective primary health care is the cornerstone for efficient, people-centred, and equitable health systems everywhere. Across OECD countries and beyond, investing in primary health care pays off.