Editorial: Why changes in primary care will affect integrated care

Citation

Kaehne, A. (2023), "Editorial: Why changes in primary care will affect integrated care", Journal of Integrated Care, Vol. 31 No. 1, pp. 1-2. https://doi.org/10.1108/JICA-02-2023-090

More and more emphasis in health service integration is placed on the role of primary care. What it means to have a “family doctor” may have changed over the last decades, but its key function of assessing, referring and treating patients remains the bedrock of our health systems. Or does it?

Ever heard of the Amazon Clinic? Or One Medical? Neither had I until recently. For those who are practicing, researching and believing that primary care is the immutable core of our health systems, you are in for a shock. About half of all young people (so called millennials) have not registered with a general practitioner (GP). They are drawing on health services which are provided ad hoc or through membership (One Medical) conveniently through virtual means where possible or face to face where needed. The disruption this will cause in our health systems is immeasurable.

Take access, one of the triple aims of our health policy. In most health systems, primary care doctors have a gatekeeper function which allows us to conveniently measure access, and equality of access, to health care services by looking at who is registered with GPs and who gets what, which, in the parlance of the field, is called “service utilisation” patterns. But how to measure access if younger people do not see the need to register with a GP anymore, circumventing the conventional primary care sector altogether?

Or take service planning and commissioning. The last decades have seen a significant shift of these functions to centres of local control where primary care doctors have assumed an active role, in some countries even gaining the responsibility to fund (or buy) health services in the area. Hospitals and community providers have readjusted themselves to these new realities, working in close cooperation, for example in England, with Primary Care Networks (a group of GP practices) to identify, plan and provide services for the community. If young people do not see the benefit of registering with a local GP, how can we plan and design the area’s health care provision?

This brings us to integration. Integration, at the system level, is predicated on the system’s ability to project health care needs of populations as well as to identify and address health inequalities through data, which in turn depends on people “turning up” at their GPs.

But why should one register with a GP in the first place? The old family doctor who has a long standing history of care with you and your loved ones is long gone. Young people’s behaviour of drawing on public services is radically changing, with most services being accessed online nowadays. This jars with GP practices which still send (hardcopy) letters to people at their home informing them about upcoming appointments, where most of these letters are simply added to the heap of unopened post piling up in the homes until they are summarily dropped in the kitchen bin.

In England, if you wanted to make an appointment with your GP, the facility of making online appointments (so popular during the pandemic) has long been switched back to face-to-face appointments. The reason why GPs moved away from such temporary innovation in the primary care sector? The demand for online appointments was too large and, as GPs pointed out, there are enough patients willing to trot to the surgery in the morning to wait for an appointment. We often talk about barriers to health care services. But such antediluvian appointment practices are more like a Berlin Wall to any young person who has neither the privilege nor the time to turn up at a GP surgery in the morning to wait for hours to grab one of the precious appointment slots with their local doctor.

And why should they? Their health problem may not be acute, so this is where a new service such as Amazon Health come in. It promises to “deliver convenient, affordable care … virtually”. Why go to a GP if all you need is a video consultation and a simple prescription to treat your skin rash. In sum, our primary care system is slowly navigating itself into irrelevance for large sections of our populations because of its refusal to innovate or be responsive to the way people like to consume health services. In a sense, primary care is abjectly negligent of profound behavioural changes in our societies.

You think this is future talk? It may be for now. Health systems have a way of doggedly resisting change. Their most cherished policy in the face of change: disregard it. The NHS is a case in hand. Despite all its hard working professionals, the NHS as an organisation cares little about patients. If some patients do not come through the door (metaphorically and literally), that is part of the system’s “rationing” and of course factored into service planning. But it should concern us. Our health systems are founded on equity and solidarity, the foundations of which are individual contributions (through tax or insurance) to our common population health. We are better off altogether if we share risks by providing health services to all of us and fund them jointly.

So far, in many countries health systems are provided through a no choice model, which is structured through gatekeeper functions of GPs. This is likely to change. And care integration built on the bedrock of a unified primary care sector is likely to have its comeuppance. Things are about to get a lot more fragmented as young people vote with their feet and commercial organisations move into the fray. Exciting times ahead.