What are the advantages and

disadvantages of restructuring a health

care system to be more focused on
primary care services?

January 2004
 ABSTRACT

This is a Health Evidence Network (HEN) synthesis report on the advantages and disadvantages of restructuring
a health care system to be more focused on primary care services.

The available evidence demonstrates some advantages for health systems that rely relatively more on primary
health care and general practice in comparison with systems more based on specialist care in terms of better
population health outcomes, improved equity, access and continuity and lower cost.

This report is HEN’s response to a question from a decision-maker. It provides a synthesis of the best available
evidence, including a summary of the main findings and policy options related to the issue.

HEN, initiated and coordinated by the WHO Regional Office for Europe, is an information service for public
health and health care decision-makers in the WHO European Region. Other interested parties might also benefit
from HEN.

This HEN evidence report is a commissioned work and the contents are the responsibility of the authors. They
do not necessarily reflect the official policies of WHO/Europe. The reports were subjected to international
review, managed by the HEN team.

When referencing this report, please use the following attribution:

Atun R (2004) What are the advantages and disadvantages of restructuring a health care system to
be more focused on primary care services? Copenhagen, WHO Regional Office for Europe (Health
Evidence Network report; http://www.euro.who.int/document/e82997.pdf, accessed 20 January
2004).
Keywords
DELIVERY OF HEALTH CARE – ORGANIZATION
AND ADMINISTRATION
PRIMARY HEALTH CARE
EVALUATION STUDIES
QUALITY OF HEALTH CARE
PATIENT SATISFACTION
HEALTH SERVICES ACCESSIBILITY
COST-BENEFIT ANALYSIS
DECISION SUPPORT TECHNIQUES
EUROPE

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What are the advantages and disadvantages of restructuring a health care system to be more focused on primary
care services?
WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004

Summary .................................................................................................................................... 4
The issue................................................................................................................................. 4
Findings.................................................................................................................................. 4
Policy considerations.............................................................................................................. 4
Introduction ................................................................................................................................ 5
Sources for this review........................................................................................................... 5
Defining primary and specialist care...................................................................................... 6
Findings from research and other evidence................................................................................ 6
Population health and aggregate health expenditure.............................................................. 6
Equity and access ................................................................................................................... 7
Quality and efficiency of care ................................................................................................ 7
Cost effectiveness................................................................................................................... 8
Patient satisfaction.................................................................................................................. 8
Generalizability .......................................................................................................................... 9
Discussion .................................................................................................................................. 9
Conclusions .............................................................................................................................. 10
References ................................................................................................................................ 11
Annex 1. Defining primary and specialist care ........................................................................ 16

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What are the advantages and disadvantages of restructuring a health care system to be more focused on primary
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WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004

Summary

The issue
Governments are searching for ways to improve the equity, efficiency, effectiveness, and
responsiveness of their health systems. In recent years there has been an acceptance of the important
role of primary health care in helping to achieve these aims. However, there have been no systematic
reviews on primary care versus specialist-oriented systems, nor has the case for primary health care
been firmly established.

This review presents the evidence for the advantages and disadvantages of restructuring a health care
system on primary care services. It is based on a rapid but systematic review of key sources of
published literature. The evaluation of evidence is complex for a number of reasons, including
differing definitions of services, staff and the boundaries between primary and secondary care,
changing organizational structures, and an increasing reliance on primary care teams. No studies were
found that specifically addressed the advantages of health care systems relying on specialists.

Findings
International studies show that the strength of a country’s primary care system is associated with
improved population health outcomes for all-cause mortality, all-cause premature mortality, and
cause-specific premature mortality from major respiratory and cardiovascular diseases. This
relationship is significant after controlling for determinants of population health at the macro-level
(GDP per capita, total physicians per one thousand population, percentage of elderly) and micro-level
(average number of ambulatory care visits, per capita income, alcohol and tobacco consumption).
Furthermore, increased availability of primary health care is associated with higher patient satisfaction
and reduced aggregate health care spending. Studies from developed countries demonstrate that an
orientation towards a specialist-based system enforces inequity in access. Health systems in low
income countries with a strong primary care orientation tend to be more pro-poor, equitable and
accessible. At the operational level, the majority of studies comparing services that could be delivered
as either primary health care or specialist services show that using primary care physicians reduces
costs, and increases patient satisfaction with no adverse effects on quality of care or patient outcomes.
The majority of studies analysing substitution of some services from secondary to primary care
showed some such shifts to be more cost-effective. The expansion of primary health care services may
not always reduce costs because it ends up identifying previously unmet needs, improves access, and
tends to expand service utilization.

Policy considerations
The available evidence demonstrates some advantages for health systems that rely relatively more on
primary health care and general practice in comparison with systems more based on specialist care in
terms of better population health outcomes, improved equity, access and continuity and lower cost.
However, a stronger evidence base is needed to make the evidence available universally applicable.

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What are the advantages and disadvantages of restructuring a health care system to be more focused on primary
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WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004

The author of this HEN synthesis report is:

Dr Rifat Atun
Director, Centre for Health Management
Tanaka Business School
Imperial College London
South Kensington Campus
London SW7 2AZ
Tel: +44 (0) 20 7594 9160
Fax: +44 (0) 20 7823 7685
E-mail: [email protected]

Introduction
Globally, governments are searching for ways to improve equity, efficiency, effectiveness, and
responsiveness of their health systems. The WHO World Health Report identifies many countries that
fall short of their performance potential (1). There is no agreement on optimum structures, content,
and ways to deliver cost-effective services to achieve health gain for the population.

In recent years there has been an acceptance of the role of primary health care (PHC) in providing cost
effective health care (2, 3, 4). However, the advantages and disadvantages of health care systems that
rely on medical specialists versus the systems that rely more on general practitioners and primary
health care have not been systematically reviewed or a case for primary health care firmly established.
This paper assesses the empirical evidence for them through a review of studies published in the
period 1980-2003. A discussion of the generalizability of findings follows. It also explores definitional
issues related to primary health care.

In this review, the terms primary health care, primary care and general practice are used
interchangeably. Generally, primary care and general practice refer to primary medical care, which in
the WHO definition of primary health care form only a part of a greater set of aims and activities, as
described in the next section.

This study was inherently complex due to a number of factors.

• There are varied definitions of the scope and role of general practice, primary care, primary
health care and specialists. For instance, a primary care team can vary from a community nurse,
a feldsher or rural general practitioner to a multidisciplinary team of up to 30, comprising
specialist nurses, managers, support staff, family medicine and other primary care specialists.
• The boundaries of primary and secondary care differ among and within countries, making
comparison and generalizability of studies particularly challenging.
• Organizational structures in many countries are changing, giving way to integrated institutions
comprising primary and secondary care.
• In many health systems, services traditionally provided by secondary care specialists are now
the responsibility of the primary care team, making a definite distinction between secondary and
primary care specialists difficult.

Sources for this review

The review is based on a detailed search using key sources of literature including: PubMed; Medline;
EMBASE; Social Science Citation Index (BIDSS); National Centre for Reviews and Dissemination
(UK); DARE; CRD Reports; NHS Economic Evaluation Database; Agency for Health Care Policy
and Research; ScHARR; World Bank Registers, World Health Organization and the Cochrane
Library.

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What are the advantages and disadvantages of restructuring a health care system to be more focused on primary
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WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004

The search was focused to identify evidence in the following areas:

• international comparisons of primary care and specialist led care and their effect on equity of
access, health outcomes, and patient satisfaction
• the relationship between access to primary care and health outcomes, patient satisfaction and
cost
• continuity of care and health outcomes
• substitution of primary care for hospital care
• shared primary care and secondary care being as good as secondary (specialist) care only
• comparison of the effectiveness of GPs (primary care physicians) and hospital specialists.

The review follows validated methods for critical appraisal (5, 6), and includes studies with the
following designs: systematic reviews, randomized controlled trials (RCTs), quasi-experiments,
evaluative studies and case control studies. Leading editorials focusing on the concept and trends are
also included. Language limitations of the author meant that only publications in English and Spanish
were reviewed. Studies in other languages, descriptive studies, and case studies with no evaluation
criteria or clear purpose were excluded. In the search, 1300 documents were retrieved. Of these, 256
were judged to be relevant for the study and 111 papers were considered to be of sufficient quality for
detailed review and inclusion in the assessment.

While the author attempted to systematically weigh the evidence, it should be made clear that due to
time constraints, this is not a formal systematic review.

Defining primary and specialist care

Specialist care is defined as those services delivered by narrow specialists, usually in hospital or in an
ambulatory setting and those not delivered in primary care. Defining primary care is fraught with
difficulties. An attempt to do so in the United States yielded no fewer than 92 definitions (7).
Similarly, in the European region, the definition of PHC varies by country (8, 9). Primary care
definitions can be considered in terms of concept, level, content of services, process and team
membership. A detailed discussion on this is given in Annex 1.

Findings from research and other evidence

Population health and aggregate health expenditure

A recent study assessing the contribution of primary care systems to a variety of health outcomes in 18
wealthy OECD countries over three decades revealed that the strength of a country's primary care
system was negatively associated with population health outcomes such as all-cause mortality, all-
cause premature mortality, and cause-specific premature mortality from major respiratory and
cardiovascular diseases (10). Stronger primary care meant better health outcomes. This relationship
was significant even while controlling for determinants of population health at macro-level (GDP per
capita, total physicians per one thousand population, percent of elderly) and micro-level (average
number of ambulatory care visits, per capita income, alcohol and tobacco consumption). Furthermore,
PHC characteristics such as geographic regulation, longitudinality, coordination, and community
orientation were associated with improved population health. This reinforces findings of an earlier
international comparison involving 11 developed countries which demonstrated that a higher primary
care orientation of a health system was more likely to produce better population health outcomes, at
lower cost, and with greater user satisfaction (11).

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WHO Regional Office for Europe’s Health Evidence Network (HEN)
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In a comparative study in the United States, Shi demonstrated that availability of primary care
physicians correlated positively to favourable health outcomes, including age-adjusted and
standardized overall mortality, mortality associated with cancer and heart disease, neonatal mortality,
and life expectancy (12), whereas absence of a primary care source was found to be the most
important factor in determining poor health (13). In contrast, health systems dominated by specialists,
such as that of the United States, have higher total health care costs and reduced access to health care
by the vulnerable populations (14, 15, 16). The high cost is attributed to proportionately low numbers
of primary care physicians and consequent impairment of the gate-keeping function (17, 18). Areas of
the United States with lower rates of primary care physicians per population have higher Medicare
(federal health insurance mainly for people 65 years of age or older) expenditures (19).

Primary health care, when compared with secondary care, is a lower cost environment as services
delivered by specialists are higher cost due to a tendency to use expensive technology and orientation
to curative rather than preventive medicine (18).

In developing countries, systematic international data supporting a strong correlation between

increased PHC spending or access and improved health outcomes is not strong (20), due to the
inherent difficulty of disaggregating socio-economic and health system interventions.

Equity and access

In low-income countries, evidence shows that expenditure on PHC is more pro-poor than aggregate
expenditure that includes hospitals, and has a desirable distributive impact benefiting the poorer
segment of the population proportionately more than the richer segment (20). Studies from developed
countries demonstrate that an orientation towards a specialist-based system enforces inequity in access
(21). In contrast, there is general agreement that expenditure on primary care improves equity (22).
Greater investment in primary care increases access to care with associated lower mortality and
morbidity (23). Conversely, a reduction in access to PHC results in a worsening health status (24, 25).

Quality and efficiency of care

There is a paucity of rigorous studies evaluating the quality and cost effectiveness of care delivered in
the primary care setting or by general practitioners (26). A systematic review of the quality of clinical
care in general practice concluded: “The published research in the field presents an incomplete picture
of the quality of clinical care in terms of its methodological rigour and comprehensiveness” and that
“Judgements about quality of care tend to be based on fragmented information” (27).

A substantial number of well-designed studies exist comparing care delivered by general practitioners
to that by specialists. These show no significant difference in quality of care and health outcome for
care delivered by general practitioners even when substituted for secondary care specialists (28).

Primary care physicians are more likely than specialists to provide continuity and comprehensive care
resulting in improved health outcomes (29). Improved access to primary care physicians and their
gate-keeping function have added benefits such as less hospitalization (30, 31, 32), less utilization of
specialist and emergency centres (33, 34), and less chance of being subjected to inappropriate health
interventions (35). In contrast, when direct access to specialists is possible without a controlling
mechanism by primary care physicians, the quality of care, as measured by appropriateness, worsens
and health care costs increase (36). Furthermore, evidence from a systematic review suggests that
broadening access to primary care can reduce demand for expensive, specialist-led hospital care (37).

Not all studies support the evidence that the gate-keeping function of primary care improves patterns
of secondary care and hospital use (38). Some studies in selected areas of care at the primary-
secondary interface show that shifting care previously undertaken by specialists does not necessarily

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WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004

result in reduced demand for specialist or secondary care services (39, 40, 41, 42), and some confirm
the advantages of specialists for hospital inpatient care (43, 44, 45, 46). This advantage is not
observed for outpatient care (47, 48, 49).

The empirical evidence of what care can be readily shifted from specialist-led secondary care to PHC
is limited (50). Some studies analysing substitution of selected services (for instance for hypertension
and asthma) from secondary to primary care showed this shift to be more cost-effective, although
others found contrasting or ambiguous results. For instance, a comparative analysis of quality and cost
of depression treatment by primary care physicians and specialists shows the latter to be more
effective but more costly (51).

Cost effectiveness
Implicit in the literature on primary care is that hospital care is inappropriate as a first resort for and
therefore primary care is necessarily a ´good` substitute. However, this assumption must be supported
by empirical evidence. In low-income settings, the cost effectiveness of PHC compared to other health
programmes is confirmed by a review (52). This reinforces World Bank findings that selected primary
care activities, such as infant and child health, nutrition programmes, immunization and oral
hydration, appeared as “good buys” compared to hospital care (53), and that interventions deliverable
in primary care facilities could avert a large proportion of deaths (54). The Bamako Initiative in Benin
and Guinea demonstrates that even in resource-poor settings it is possible to implement and sustain
basic PHC services (55).

Shifting care across specialist-general practice and secondary-primary care boundaries is possible and
has been shown to be cost effective without an adverse affect on outcomes. For instance, general
practitioner-led hospitals in Norway provided health care at lower cost compared to alternative modes
of care, due to averted hospital costs (56). United Kingdom studies confirm that GP hospitals save
costs by reducing referrals and admissions to higher-cost general hospitals staffed by specialists (57,
58, 59). Care delivered by general practitioners, compared to hospital specialists, in hospital-based
accident and emergency departments was shown to be more cost effective with lower use of diagnostic
investigations, lower referral rates to secondary services, lower prescription levels, and no significant
difference in patient satisfaction or health outcomes (60, 61, 62).

Patient satisfaction
A comparison of 10 Western countries suggested higher user satisfaction levels for health systems
based on a strong primary care system if the influence of expenses on the health care was controlled.
The United Kingdom was an exception despite having a health system with a strong primary care
orientation and relatively low total health expenditure (63).

The Euro barometer survey of citizens of 15 European Union Member States shows that Denmark,
which has a very strong primary care system with 24-hour, 7-day access to primary care, has the
highest public satisfaction with health care (64), attributed to the value placed on the accessibility of
primary care delivered by general practitioners (65). However, patient satisfaction with primary care
and general practitioners is strongly influenced by the mode of care delivery, physician style,
availability of out-of-hours care, a named physician, continuity of care and provision of routine
screening (66, 67, 68, 69).

In the US system, gate-keeping exercised by primary care physicians preventing direct patient access
to specialist care led to patient dissatisfaction (70).

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WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004

Generalizability
Studies in the review are predominantly from the United States European countries such as the United
Kingdom, Netherlands and Nordic countries and low-income countries in Africa. Research from
transition countries, middle-income countries and Latin America is lacking.

The review revealed a paucity of high quality studies comparing advantages and disadvantages of
PHC and specialist care in Europe; comparative studies tended to be from the United States. There
were few cost-effectiveness analyses comprehensively evaluating services provided in PHC. These
were RCTs examining segments of particular interventions rather than comprehensive or integrated
management of the problem in question.

The extent to which the findings can be readily generalized to support policy recommendations is open
to debate, as the available evidence comes from a number of different countries, with a variety of
different health system structures, organization, financing and delivery modes. It is difficult to control
for these factors. Changes observed may be attributable to factors such as health system financing or
physician behaviour rather than where and by whom the care is delivered. Disaggregating the impact
of these factors from the domain, health professional, or delivery mode is difficult.

Transferring evidence or care models from one setting to another without a clear understanding of the
context and health system dynamics can produce unintended consequences. Caution should be
exercised before embarking on reforms that favour primary care-based systems and where shifts across
boundaries are concerned without clearly defining policy objectives and identifying the evidence base
to support them. Funding agencies and the research community need to be encouraged to undertake
rigorous national and transnational comparative studies to improve the knowledge and evidence bases
to inform policy decisions.

Discussion
The success of health systems in tapping the existing potential or making appropriate structural
changes to enable shifts from expensive to more cost-effective alternative sub-sectors such as PHC is
by no means universal. The extent of importance attached to primary care varies from country to
country. Despite the evidence for primary care, resource allocation in most countries still favours
hospitals and specialist care. This is partly due to perceptions about what PHC is, what it has to offer
(71), and its development as a control function to reduce costs or access to secondary care (72, 73),
rather than its positive contribution to health gain. This explains the paradox of the attractiveness of
primary care on empirical grounds and its lack of appeal to national policy-makers and healthcare
professionals, who see it as a low-grade activity with little effect on mortality and serious morbidity
and a predominant role in triage of access to hospitals.

This inefficiency in resource allocation has implications for equity and efficiency. It may explain why
increased total public spending for health has not improved equity of access and outcomes
proportionately and has had less impact on average health status than expected (74, 75).

Given the right incentives, in any health system, there is the real opportunity to expand provision of
medical services in a primary care setting (76). The lack of identity poses problems for the proponents
and funding agencies who believe that primary care is necessary (77). Policy-makers need to be made
aware of the concept of primary care and what it has to offer. This will require investment for
advocacy and marketing activities to communicate the benefits of primary care to health professionals,
policy-makers and the public.

The role of primary care should not be defined in isolation but in relation to the constituents of the
health system. Primary and secondary care, generalist and specialist, all have important roles in the
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WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004

health system. They are not mutually exclusive, but rather necessary ingredients for any system.
However, technological advances, improved education and training, broadening of the primary care
team roles and membership, different demand patterns due to health transition, and changing social
attitudes mean primary care has a greater role to play than before, and resource allocation needs to
flow in its favour.

A new approach is necessary: one in which primary care is seen in a positive light, with a proven
contribution to health gain beyond control or cost-containment functions. The approach should be
based on a comprehensive and integrated model recommended by WHO (78). The new approach
should combine new universalism with economic realism with the objective of providing coverage for
all and not coverage for everything. However, the scope, content, and expansion of this model should
be guided and supported by empirical studies (79).

Conclusions
Compared to secondary and tertiary health care sectors, primary health care seems to be a “new”
setting for research, although one can observe an increase in complexity and quality of studies in the
period surveyed. There are few transnational or pre and post-intervention studies. This is surprising
given the ongoing reforms in the European region, and particularly the transition countries, which aim
to introduce or develop primary care.

Despite the caveats concerning generalizability, the available evidence confirms improved population
health outcomes and equity, more appropriate utilization of services, user satisfaction and lower costs
in health systems with a strong primary care orientation. Findings support policies that encourage a
shift of services away from specialist care to PHC, as the substitution does not adversely affect quality
but lowers cost. Studies indicate the limits of substitution and there remain questions to be addressed,
such as the configuration of primary care structures and teams, content of services, and modes of
delivery.

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Annex 1. Defining primary and specialist care

The concept of primary care
In the Alma Ata declaration, the World Health Organization defined primary health care as “essential
health care based on practical, scientifically sound and socially acceptable methods and technology,
made universally available to individuals and families in the community through their full
participation and at a cost that the community and the country can afford to maintain at every stage of
their development in the spirit of self-reliance and self-determination.” (80). Although many transition
countries in the European Region have yet to attain a primary care level defined in the Alma Ata
declaration (81), industrialized countries in the Region have surpassed it. For these countries primary
health care can be viewed as “a strategy to integrate all aspects of health services” (82).

Primary care is seen as an “integral, permanent, and pervasive part of the formal health care system in
all countries” or as the “means by which the two goals of health services system - optimization of
health and equity in distributing resources - are balanced” (83). It addresses the most common
problems in the community by providing preventive, curative, and rehabilitative services to maximize
health and well-being. It integrates care when more than one health problem exists, deals with the
context in which illness exists and influences people’s responses to their health problems. It is care
that organizes and rationalizes the deployment of basic and specialized resources directed at
promoting, maintaining, and improving health (11).

Vuori describes the constituent components of primary health care as a set of activities, a level of care,
a strategy for organizing health services, and a philosophy that should permeate the entire health
system (84). His first component echoes the Alma-Alma definition and identifies its eight basic
elements. Primary care as a level in the health care system is the domain where people first contact the
health care system and where 90% of their health problems are dealt with. Primary care as a strategy
envelopes the notion of accessible care, relevant to the needs of the population, functionally integrated,
based on community participation, cost-effective and characterized by collaboration between sectors
of society. Primary care as a philosophy underpins equitable delivery of care with a particular
reference to intersectoral collaboration.

Primary care defined as a level of care

In 1920, the Dawson Report distinguished three major levels of health services in the UK: primary
health centres, secondary hospitals and teaching hospitals (85). Although this structure prevails in
most countries, the content and delivery in primary and secondary care have changed.

Primary care in terms of content

In many health systems, particularly in developing and transition country contexts, PHC is defined as
consisting of the basic or essential set of health interventions enshrined in the Alma-Ata Declaration
(80). This leads to equating primary care with selective vertical programmes (86, 87) or an essential
package of services used partly as a financing tool but also to meet the disease burden of
predominantly communicable disease, perinatal and maternal deaths (88). The selective primary care
approach has been widely criticized for lacking an empirical foundation (89), as a reinvention of the
traditional technically oriented vertical programmes (90), being based on value judgements (91, 92),
adversely impacting the health developmental process (93), and even for being counterproductive (94).
Some have even questioned the validity of cost-effectiveness technology as the basis for justifying
selective PHC (95).

An alternative to selective PHC is the comprehensive PHC system prevalent in many developed
countries, comprising a wide range of health education, promotion, prevention, curative and
rehabilitative, and terminal activities. Some argue that comprehensive PHC is also affordable and
deliverable in developing countries (96).

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In the European Region, the set of activities devolved to primary care is growing rapidly. Much of
specialist outpatient care is shifting to primary care via the outreach clinics encouraged by shared-care
schemes (97). Even inpatient services traditionally provided in hospitals by the specialist are shifting
to primary care through hospital-care-at-home schemes (98). General practitioners are now expected to
provide emergency care for conditions that were traditionally provided in hospital accident and
emergency departments (99).

The primary care-secondary care interface is dynamic and changing, as are the boundaries between
general practitioners and primary care physicians or hospital specialists. There is considerable
overlapping of roles of general practitioners giving specialized care and specialists providing general
practice services, the so called “hidden primary care” (100, 101), further complicating the
comparability of research findings in different countries and contexts.

Primary care as a key process

Primary care is often equated with a gate-keeping role (102). However, it plays a more fundamental
role than just gate-keeping; it is a key process in the health system (103). It is the first contact, front-
line, ongoing, comprehensive and co-ordinated care (104). First contact care is accessible at the time
of need; ongoing care focuses on the long-term health of a person not on the short term duration of the
disease; comprehensive care is a range of services appropriate to the common problems in the
population available at the primary care level, and; co-ordination is a role by which primary care acts
to co-ordinate other specialist services that the patient may need.

Primary care defined in terms of team membership

Primary care teams can vary from community nurses, feldshers, or rural general practitioners to
multidisciplinary teams of up to 30, comprising specialist nurses, managers, support staff, family
medicine and other primary care specialists.

The Royal College of General Practitioners in the United Kingdom describes a primary care
professional as “any health professional whose professional qualification is in health care, whose
professional qualification is recognized by a statutory registration council approved by Parliament,
who sees clients/patients directly without any referral from a health professional, or who works within
a primary medical or nursing care organization that offers patients open access” (105).

In the industrialized countries of the European region the core primary care team often consists of a
general practitioner, a community nurse, practice nurse, social worker, therapist and administrative
staff (106). Although in countries where primary care is well developed, team membership exceeding
20 is not unusual (11) (Table 1).

Table 1: Membership of the primary care team

Medical Paramedical Administrative Therapists Social
General Community Practice manager Physiotherapist Social worker
practitioner nurse
Dentist Practice nurse Receptionist Chiropodist Community
psychiatrist
Community Ophthalmic Assistant Speech therapist Psychologist
geriatrician optician
School medical Midwife Secretary Osteopaths Counsellor
officer
Health Visitor Dietician Domiciliary aid
Pharmacist

Although general practice is an integral part of primary care, the terms are not synonymous. The role
of the general practitioner gives an indication of the breadth of the primary care services provided and
the degree of uniformity in the services. In industrialized countries, the GP is the only clinician who
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operates in the nine levels of care: prevention, pre-symptomatic detection of disease, early diagnosis,
diagnosis of established disease, management of disease, management of disease complications,
rehabilitation, terminal care and counselling (107).

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