Primary Care Strategy
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Introduction
“Primary care is the first point of contact that people have with the health and personal social services.”[1] This means that primary care must be sufficiently well developed to be able to address the most complex and diverse range of health-related challenges and problems that will manifest in healthcare service provision, and make the most of opportunities to promote health and reduce morbidity, across the general population in specific target groups. This essay will explore the Republic of Ireland’s primary care strategy in relation to key goals and targets, and also examine some elements of the strategy in terms of a SWOT analysis. Specific reference will be made to the role of the Specialist Public Health Nurse/Health Visitor Role.
Main Body
Primary Care can be defined as “first contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or organ system.”[2] Primary care is about the provision of information, diagnosis, treatment, referral and support for the majority of people who access healthcare services for the first time, and the strategic concerns of primary are related to accessibility, provision of short and long-term care which meets the needs of the population, assessment of those needs, and coordination of services to meet those needs[3]. This has many implications for the provision of healthcare services and the management of increasingly scarce resources.
However, it is evident from the literature that in most locations, primary healthcare services still have a long way to go in meeting the goals of primary healthcare itself, particularly in relation to improving integration of services and reorienting services to a person-centred model, rather than a disease-centred model. Primary healthcare is viewed as a means of reducing the use of and demand for overall healthcare services by acting as a gatekeeper for secondary healthcare, and as a means of primary prevention of healthcare problems and disease, particularly in high risk groups of the population, but there is ongoing evidence and debate within the academic literature that there are continuing issues about the lack of egalitarian access to such services and ongoing questions about the ways in which they are provided[4]. It is considered by some that the decisions which govern the design and delivery of primary care services are potentially more based on political drivers than true patient need[5]. Similarly, the gateway function of the primary care service in determining which patients have access to acute care (or secondary care) services may not be based on individual need, but on other factors, such as political, social and even personal factors, including prejudices on the part of healthcare professionals[6]. The primary care strategy, if it provides strong guidance which leads to strong leadership, and perhaps enhances management of care through the use of agreed care pathways which guide decision making, might help eradicate some of these factors. Making the person-centred care model central will also help to remove some of the barriers to egalitarian service provision[7]. However, one of the challenges of the Republic of Ireland model is the fact that two thirds of patients in primary care must pay for their care, which would mean that despite the focus on removing inequalities in access, there continue to be challenges for providing equality of access[8].
One of the strengths of the primary care strategy is the focus on improving interprofessional working and communications, as a means of streamlining use of services and preventing doubling up or overlap of services[9]. Improving interprofessional working at the primary care level is one thing, but the strategy also needs to ensure that the intersection between primary and secondary care is properly managed, and that patients moving from acute care settings into community settings continue to have a streamlined, person-centred model of care applied, with good continuity of care[10]. However, there is also a need for the provision of strong leadership, which supports the implementation of the changes associated with this re-orientation of primary care in Ireland, and which supports new ways of working and helps to break down the barriers between the professions[11], [12].
This is where the role of the Health Visitor can be examined in a little more detail, in relation to realising some of the goals of the Primary Care Strategy, and in addressing some of the challenges of this. It has long been the case that Health Visitors work across professional boundaries, and work closely with a range of other health professionals, because within the community, specialist and generic roles are equally required in supporting individual patient need[13]. The interprofessional interface is perhaps one of the most fundamental elements of the work of the Health Visitor, but at the same time is perhaps not given enough attention or credit in terms of the impact that Health Visitors have in the prevention of illness and public health sectors of primary healthcare[14], [15].
The Public Health focus of the primary care strategy is inherent in much of the rhetoric it contains, particularly as it expressly cites the potential for preventive strategies to reduce overall healthcare resource use[16]. It is here that the Health Visitor’s role perhaps has the greatest scope, and should be more strongly underlined, as this is a great resource for change. Research shows that the role of the health visitor is paramount and unparalleled, in reducing risk related behaviours, improving health outcomes, promoting healthy lifestyles and engaging in the more challenging areas of the health/social car interface[17], [18], [19]. However, there is also some evidence to suggest that nurses and, in particular, health visitors, have a key role to play in expanding and delivering the public health dimension of primary care[20]. In particular, the development of improved partnerships in health and social care may be made possible through the role of such nurses, who have the broader community knowledge as well as specialist knowledge of key areas of public health[21]. These partnerships can be developed with a focus on the quality of care provision, not just the identification of need[22], [23], [24]. However, managing the development of improved partnerships, and achieving the goals of the Strategy, is going to be challenging during the transition period, and there may be a degree of uncertainty over roles and boundaries[25]. It might be that Health Visitors are in a prime position to provide the leadership required during such a time.
Conclusions and Recommendations.
Below is a summary of a brief SWOT analysis of the primary care strategy and isome of its potential implications.
Table 1 SWOT analysis of Primary Care (with Reference to the Republic of Ireland Primary Health Strategy[26])
Strengths
Weaknesses
Opportunities
Threats
Enhanced governmental commitment to funding and infrastructure
No clear guidance on how resources will be used and if this is the best use of such resources
Improve interprofessional networking and team-working
Medical and other professional hegemony and resistance to blurring of professional boundaries[27], [28].
Clear strategy with delineated goals and outcomes
More detail of implementation and impact on service providers needed
Build on existing skills base
Lack of recognition of the true extent of skills base; lack of flexibility and responsiveness to adapt to using existing skills of staff.
Primary care as the single/primary point of entry into health and personal social care services.
Not enough detail on impact of transition to new model – transition period could have negative impact on staff/patients
Increase personnel resourcing
Inability to locate/recruit personnel to key positions and with the correct skills
Community Focus
Lack of clarity about impact on secondary health care services
Development of academic practice and research[29]
Competition with academic providers
Integration of services with public involvement and user—focused development of services
Lack of clarity about how needs assessment will be carried out, and by whom – lack of transparency about prioritisiation of resources
Inclusion of all grades of staff, not just healthcare professionals, in the defined Primary Care Team.
Lack of skills of some staff to use up to date ICT resources
This shows that while there are issues with weaknesses and threats, many of these are the kind that have been present within the primary arena for some time, and it will take good leadership, and good use of existing skills and resources, to achieve the goals of the strategy. While the primary care focus for healthcare services is laudable, there is still the overwhelming need for good resourcing, more clarity about provision, and clear guidance on how to move forward to achieve these goals. Making use of existing roles, such as that of the Health Visitor, whose work crosses the intersections of care at so many points in the primary care sector, could improve quality of care, reduce the impact of the change and transition, and also set standards for the future to increase interprofessional communication and partnership. Certainly it should not be assumed that the strategy will eradicate all the existing problems about the provision of primary care in Ireland, and those problems must still be addressed in future provision[30].
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