Primary care gaps: what's failing and how can we fix it?

Pere Vivó

The health crisis is placing unprecedented strain on the health care system and in particular on primary care. Saturated agendas, disorganized demand and forced abandonment of some functions to assume new competencies, all added to the social crisis and the extra demand on the part of some users have as a result a generalized discouragement and psychological exhaustion of professionals.

But how did we get to this point? Let's analyze the five main "gaps", their causes and, most importantly, what can be the way to improve them. Let's get started!

1. Accessibility gap

Was primary care accessible in the pre-COVID era? As we pointed out in the post "The doctor gives me three weeks; can you send me to emergencies department?" accessibility was already presenting serious difficulties. Despite this, any user could request a face-to-face appointment with their professional of reference through various channels such as external call centres, visit scheduling websites or, in case of immediate need for care, directly in the health care centres. All these routes have been practically abruptly cancelled due to the pandemic.

And then, what can a user do who wants to access his health team now? The alternatives go through the arduous telephone contact with the centres, through the electronic consultation directed to the health care professional or by writing the user's need in an open web forum that the health care centre will resolve in a deferred manner.

This new scenario in which, due to overflow, user demand is not resolved with agility, is interpreted as a barrier and conveys a feeling of inaccessible primary care that contributes to collective tension.

To overcome this "gap", why don't we take advantage of this moment to implement a scheduling system for reasons, capable of differentiating bureaucratic consultations from health-related ones? Why don't we integrate our portfolio of services differentiated by professional categories into the visit scheduling platform? Why don't we stipulate reasonable response times for each demand and thus adjust expectations?

2. Technological gap

Are we ready for electronic consultations and video consultations? The answer is probably not. In addition to the obsolete technological equipment, health care professionals do not yet have the codes of conduct or drafting necessary to handle this new medium and preserve the human connection in the virtual consultation.

Furthermore, not all the entire population has access to the technological elements necessary for this system to function properly, so this accelerated change in the model could be generating equity problems in health care.

What if, to be able to solve it, we equip the health teams with the necessary technological resources? Why don't we start a training program in communication skills and the use of new technologies? What if we also involve customer service professionals and other community agents in the training of these tools?

3. Patient safety gap

Despite the trend to make health care more technical, the fundamental tools for any doctor are the anamnesis and physical examination. Observing the patient, interacting with her, assessing her physical and psychological changes, analyzing her verbal and non-verbal expression or knowledge of her family environment are necessary elements for an accurate diagnosis.

So if face-to-face visits are currently marginal, how can we correctly diagnose? It’s possible that in some cases the potential of the physician is being compromised by limiting his diagnostic sensitivity and thus increasing the security breach of the system.

To improve it, why don't we look for a better balance between the non-face-to-face model and the face-to-face model? What if we specify what type of claims can be resolved electronically? Why don't we eliminate the inadequate bureaucratic burden and increase the face-to-face assistance spaces?

4. Gap due to lack of value

Do all the activities carried out by a health care professional add value to the patient? Certainly not. We have identified those practices that, due to their scientific endorsement, entail a direct benefit to the health of the patient and also those practices of little value that constitute inefficient historical inertia. The latter, unfortunately, we have transmitted to patients and have consolidated as new needs that even colonize our electronic consultations.

What if we carry out a strong and structured clinical approach in the system to definitively eliminate these practices? Why don't we involve more members of a health care team in monitoring stable chronic processes?

5. Vocational gap

Family medicine is no longer attractive and is going through a crisis of recognition that begins in the faculty itself, where it does not even exist as a specific discipline. Nor is there a strategic and budgetary bet that guarantees a primary model, as recommended by the WHO. Added to this is the fact that the family doctor is seen by many users as a simple gatekeeper necessary to reach other health care spaces.

And how are the professionals? Well, many of them are stagnant, others deeply resigned and lacking motivation and, now, due to the pandemic, they are living with uncertainty in the form of volatile and sometimes contradictory organizational decisions. This scenario takes us away from our true purpose and sets in motion a dangerous talent spinning machine with unpredictable consequences.

These "gaps" and many others are demonstrative that primary care is weakened and the usual inefficiencies are now more present than ever. The future, although uncertain, is full of opportunities, but to take advantage of them and be successful, someone should realize that, while primary care fails, the entire system will be sick.