Health policies and legal basis

Strong primary care needs a multi-level and intersectoral management to address its political, cultural, social, environmental, and economical components. Furthermore, an approach with enhanced horizontal and vertical relationship between governance levels and a synergistic perspective across sectors, institutions, communities, cities, and even countries is of great importance for an equal and comprehensive primary care service (WHO, 2020b). Especially, governance functions (eg, goals, policy-making, and definition of financing and regulatory mechanisms) impact primary care performance at practice and provider level, and according to up-to-date studies, its effectiveness is related to decentralization and financial regulation (Espinosa-González et al., Reference Espinosa-González, Delaney, Marti and Darzi2019).

All practices, including primary care, should have well-developed organizational and clinical systems in place documented by their policies, protocols, and procedures. In addition, developing policy documents in primary care practice is the major indicator in The European Primary Care Monitor which was developed by Kringos et al. (Reference Kringos, Boerma, Hutchinson and Saltman2015). A vision on primary care should be clearly laid down in policy documents by government or important stakeholders. Also, a dedicated department or unit is required for a strong primary care within the health management scheme.

In a technical paper on governance of health published by WHO in 2020, four strategic levers for primary care are mentioned; these are political commitment and leadership, governance and policy frameworks, funding and allocation of resources, and the engagement of communities and other stakeholders. Actions and interventions related to all levers, in particular those related to governance and finance, need to be developed using an inclusive and ongoing policy dialogue that engages the community as an actor. For the balanced functionality of these levers, the scope of the existing policy should be increased, and the community should be organized as an actor (WHO, 2020b). In order for this organization to be carried out in the best way, the management should be transformed into a guidance position by shedding its role as a service provider. Although this adaptation will develop slowly, especially in low- and middle-income countries, it is important for inclusive and effective primary care services.

As a result of the data accumulated over the years in the literature, it has been seen that besides its successes the public governance system also has limitations like shortage of human resources, inefficient institutional frameworks, inadequate quality, and efficiency due to a lack of competition (Joudyian et al., Reference Joudyian, Doshmangir, Mahdavi, Tabrizi and Gordeev2021). In addition, current studies on low- and middle-income countries have shown that well-managed multidisciplinary teams are successful with the engagement of the public and private sectors of the community-governed primary healthcare system (Bitton et al., Reference Bitton, Fifield, Ratcliffe, Karlage, Wang and Veillard2019). Therefore, a whole-of-society approach can enable the government to work together with all other stakeholders for a common goal. By engaging the private sector, civil society, communities, and individuals, the whole-of-society approach can strengthen the resilience of communities to withstand threats to their health, security, and well-being (WHO, 2020b).

Recent experience with global COVID-19 pandemic showed that countries having a prepared pandemic plan and a strong primary care system did not necessarily experience lower COVID-19 mortality rates; what appears to make a difference is planned and prompt response, and the degree to which primary care is mobilized to respond. Effective primary care responses with smooth integration with public health measures lead to lower mortality from COVID-19 (Goodyear-Smith et al., Reference Goodyear-Smith, Kinder, Mannie, Strydom and Bazemore2020). This is an important lesson showing prompt emergency response, and public health integration should be taken into account as far as governance of primary care is concerned.

Accountability

Accountability in primary care is one of the main governance tools. WHO defines accountability as being answerable to someone for decisions and actions (WHO, 2020b). Accountability is a multidirectional concept within and between organizations; vertical accountability relationships typically exist between government and providers of PCOs and public; horizontal accountability relationships are seen commonly between primary care providers and public and associations (Aday and Andersen, Reference Aday and Andersen1974). Interrelations and interconnectedness of all these partners form the basis of accountability.

Accountability has five essential components: legal, financial, professional, political, and public. These five components affect the success of primary care outcome, goals, cost-effectiveness, and satisfaction of patient’s/healthcare professionals, and all these components need to be provided for PCO accountability (Aday and Andersen, Reference Aday and Andersen1974; Joseph and Phillips, Reference Joseph and Phillips1984; Dewulf et al., Reference Dewulf, Neutens, Weerdt and Weghe2013). To strengthen and improve the accountability in primary care, the ministry should be in constant consultation with all stakeholders in primary care. Developing clear and measurable goals (patient/provider satisfaction, resource utilization, access to care, etc.); policies and monitoring tools for accountability requirements is crucial. Government, professional bodies, and primary care providers should know their roles and responsibilities, and people should take up their role as a partner in health care for more accountable primary care (Aday and Andersen, Reference Aday and Andersen1974; Joseph and Phillips, Reference Joseph and Phillips1984). In addition, primary care providers should be accountable in terms of their social role. Accountability mechanisms may vary across the delivery models. The core of ensuring accountability is to define it, guarantee the involvement of all the relevant stakeholders, be realistic, and monitor the job satisfaction of providers in primary care at a good level.

Resilience

Another aspect of the governance of a strong primary care is resilience. Resilience is a dynamic and flexible skill. Strong primary care systems must be able to adapt to changing environments and apply innovative solutions, so they need to be resilient. To establish a resilient primary care, stable funding mechanisms, risk assessment methods, good governance with well-defined responsibilities of skillful healthcare workers, building strong networks, ensuring sustainability are the essential elements (Ezekiel, Reference Ezekiel1996; Dowling et al., Reference Dowling, Sheaff and Pickard2008). Besides the resilience of primary care as a system, individual provider’s resilience is also important. A successful primary care team leader is the one who could enable resilience in his/her primary care team. Stress management abilities, self-awareness, social competence, and reflective clinical practices are useful tools to improve primary care providers’ resilience (Brinkerhoff, Reference Brinkerhoff2004).

The recent pandemic of COVID-19 is testing the resilience of health systems, even in well-resourced countries. Its challenges have brought into focus the need to protect our global health with more sustainable primary care within a well-coordinated health system that has strong government and public support for its policies. However, to achieve this, primary care needs to have adequate resourcing and ability to strengthen its capacity to maintain essential services (Huston et al., Reference Huston, Camplbell, Russell, Goodyear-Smith, Phillips, Well Van and Hogg2020).

Financing primary care: current and recurrent challenges

Primary care services are essential for the well-functioning of any health system regardless of its national configuration. Strong primary care systems provide through multidisciplinary teams a community orientation intertwined with public health and social services in addition to the first level of care that brings access to other levels of care. Multiple levers are needed to improve primary care as set forth by the renewed Declaration of Astana (WHO, 2018b) and instrumentalized through the Operational Framework (WHO, 2020b). Among the core strategic levers, funding and allocation of resources seeks to provide adequate funding allocated to promote equity in access, provide an incentive environment to enable high-quality care, and minimize financial hardship. Therefore, how we do fund primary care and reward health professionals becomes tantamount to strengthening not only the primary care sector but also the entire health system.

Looking at how primary care professionals are rewarded, diverse payment modalities have been experimented to incentivize primary care doctors and nurses, being the most used salary, capitation, fee for service, and pay-for-performance schemes. Each payment scheme introduces different incentives and disincentives to activity, quality, and performance that need to be balanced and adjusted in relation to the intended objectives. There is not an optimal payment model that stands out. Most health systems have opted for a mixed system combining salary and pay-for-performance or capitation and fee for services. For instance, the caveats on productivity brought by salary schemes can be compensated by pay-for-performance incentives that health organizations use to align primary care activities to health priorities.

From an aggregated perspective, the funding assigned to the primary care sector is also of vital importance and a significant signal to the health ecosystem of organizations and professionals. Despite the central and capital role, primary care has been often neglected from a resource allocation perspective due to diverse and historical reasons. In advanced primary care systems, this allocation ranges between 15 and 20% of the healthcare budget in contrast with more than 50% absorbed by hospitals. Initiatives like 30 by 2030 (De Maeseneer, Reference Maeseneer, Li, Palsdottir, Mash, Aarendonk, Stavdal, Moosa, Decat, Kiguli-Malwadde, Ooms and Willems2020) appeal to raise the amount of resources allocated to primary care services up to 30% of the national healthcare expenditure aiming at achieving universal health coverage and a prevention-driven health and care system.

Against the backdrop of the current epidemiologic context, the role of primary care to respond effectively to the pandemic challenges is clearer. Through contact tracing, community action at care homes, or massive vaccination, while preserving services to non-COVID conditions, primary care performance has been uneven depending on its pre-crisis capacity. Bolstering primary care with more resources and better-adjusted payment systems to incentivize preventive activities and integration of care will remain as recurrent challenges for the years to come.

Interprofessional team

When we consider the definition of primary health care, agreed by WHO in the Declaration of Astana in 2018, it becomes obvious that primary care cannot be delivered effectively unless all parts of the primary care team can work together (WHO, 2018a). Strong, community-oriented primary care that meets the needs and health outcomes for patients, families, and communities in a context of Universal Health Coverage demands strong interprofessional working. The interprofessional team will vary in its constituents from one healthcare system to another (Freund et al., Reference Freund, Everett, Griffiths, Hudon, Naccarella and Laurant2015), but can essentially be the general practitioner and nursing staff, and in the wider team includes physiotherapy, occupational therapy, midwife, community pharmacist, dentist, public health practitioner, physician’s assistant, social workers, and podiatrist. In some primary care settings, counseling, psychology, and mental health services are also offered. This array of expertise demands appropriate coordination and organization to meet the health needs of individual patients, and the community, in order to provide primary care that is integrated with other services. Interprofessional teams need support to collaborate well together. Each member of the team brings their own expertise, the skills, and competencies they have been prepared for in their professional training and their ability to contribute to the holistic care of the patient and their family, within the community. It seems incontrovertible that alongside the medical skill of diagnosis and prescribing of treatment, referral to secondary care, the skills of wound care, chronic disease management, pain management and rehabilitation, patient education and counseling and public health should be carefully planned and navigated for each patient care plan. Crucially, the skill mix should include the patients’ own expertise about their health, illness, and background experience as an essential component of integrated care. Patient involvement and participation in their own health care is now an accepted and expected element of the skill mix, especially with the wide availability of digital health and social media that support patients to develop their knowledge and make informed decisions.

There are studies and a few systematic reviews published but rarely have they attempted to assess cost-effectiveness in relation to coordination. A recent qualitative study in the United Kingdom compared three different practices introducing non-medical skill mix and concluded that it was a complex process and that ‘Recognition of factors affecting the assimilation of roles may help to better align them with the goals of general practice and harness the commitment of individual practices to enable role sustainability’ (Nelson et al., Reference Nelson, Bradley, Martindale, McBride and Hodgson2019). The study is based on 22 qualitative interviews and provides important evidence of process but cannot answer questions of cost against quality and health outcomes. As concluded by Williams et al., there remains a significant need for well-designed studies of the effectiveness of skill mix in primary care (Williams et al., Reference Williams, Medina, Wright, Jones and Gallagher2010).

Within this framework, there are still some important unanswered questions within current literature and policy documents. Some of these questions need to be answered with new data and research are ‘Does interprofessional working in primary care with a skill mix enhance equitable access to health care, who should coordinate and how is skill mix and sharing of tasks decided?’, ‘Should this be based on the demand-led (patient need) model of care or supply-led (availability and cost), how can demand and supply be balanced in relation to cost and quality of care in the light of significant workforce issues for general practitioners and nurses globally?’, ‘What contribution can patients and carers make to interprofessional working?’, ‘What evidence do we have of the cost-effectiveness of a well-coordinated skill mix in primary care that is acceptable to communities?’

Primary care practice management

Referral mechanisms

Another important factor in the quality and continuity of the primary care service is the demand management. For an appropriate referral process, a whole system approach is needed because this intervention is the first part of the network between primary and secondary care (Blank et al., Reference Blank, Baxter and Woods2014). Generally, a whole system approach is about recognizing the various elements of a health system and evaluating the nature of the links and relationships between each of them (primary, secondary, and tertiary care). Recently, e-referral and e-consultation have been preferred among the various referral methods. Although it seems to increase the responsibility and workload, e-consultation is beneficial for the primary care physician to have information on specific issues as well as for the patient to receive effective service with minimal waiting time (Lee et al., Reference Lee, Ray, Mehrotra, Giboney, Yee and Barnett2018; Liddy et al., Reference Liddy, Drosinis and Keely2016). In any case, it is possible for the patient to receive fast and effective care service, by providing accurate and comprehensive information exchange between the specialist and the primary care physician (O’Malley and Reschovsky, Reference O’Malley and Reschovsky2011).

Community orientation, social connectedness

The COVID-19 crisis has highlighted that health systems should be oriented toward communities (Johnson and Goronga, Reference Johnson and Goronga2020). On the one hand, community orientation is needed to make social interventions successful and sustainable. Health-promoting measures such as the current social distancing rules to prevent the spread of the epidemic or vaccination strategies are only effective if they are adopted and supported by a large part of the society. Therefore, social interventions should be understood and supported by the different echelons of the society. To achieve this, the involvement of communities in the development and implementation of health policies is essential. Failing to hear people’s concerns and to address them will lead to resistance.

On the other hand, community orientation is essential to reach people who are disproportionately affected by health threats. These vulnerable populations may include people with a limited social network and poor socioeconomic status, migrants, and minorities. Primary care providers often fail in reaching out to these vulnerable groups, and there is evidence that the community itself has a social capital that can contribute to accessing hard-to-reach and marginalized groups.

Also in the post-COVID-19 era, the involvement of the community in organizing health care will remain crucial for sustainable health policies that penetrate into the heart of the society (Perry, Reference Perry2018; Sacks et al., Reference Sacks, Schleiff, Were, Chowdhury and Perry2020).

Health policies are often implemented in communities and not with the communities. Although health authorities frequently call for community engagement, haziness exists about how community orientation is taken into practice. What is needed to make primary care and primary care services effectively community-oriented?

Firstly, there is a need of awareness for accountability to the community among the primary care health workers. In general, health providers are motivated to meet the needs of individual patients. At that point, social prescribing is also recommended to help patients for acquiring healthy behaviors and better managing their health problems (Drinkwater et al., Reference Drinkwater, Wildman and Moffatt2019). Conversely, primary care workers feel less comfortable in acting on a group level. This is a shortcoming in the training of the health workforce (Decat et al., Reference Decat, Demirören and De Sutter2019). Medical training institutes should make major efforts to improve the competencies of future caregivers to provide community-oriented care. The public health and primary healthcare integration should be done both at an educational and systemic levels. Place-based learning through participation at health-promoting and awareness-raising activities might be an effective strategy. The payment system of the healthcare workforce might be another limiting factor (Heider and Mang, Reference Heider and Mang2020). For providers in a fee-for-service healthcare system, there is no incentive to work with the community as they are only paid for services provided to individual patients.

Secondly, there is a need for strategies on how communities can be actively involved as partners in the development and implementation of local health policies. European health systems may learn this from strategies used in low- and middle-income countries. Settings with limited access to basic health services have developed experience in engaging communities to reach underserved populations and to promote healthy behavior (Perry et al., Reference Perry, Sacks, Schleiff, Kumapley, Gupta, Rassekh and Freeman2017). For example, the mobilization of community health workers (CHWs) to support the health workforce in maternal and child care, in health promotion campaigns, or in epidemic control is common in Latin America, Africa, and Asia. Currently, there is growing evidence that CHW programs are effective to address health inequities in high-income countries (Javanparast et al., Reference Javanparast, Windle, Freeman and Baum2018).

The current pandemic shows the urgency for bringing communities at the center of primary care. We plead to set up an international thematic network on community-oriented primary care that operates as a learning community to collect, test, and adapt strategies for training the current and future health workforce in community orientation and for engaging communities as full partners in the organization and provision of local care.

Coordination and integration of care

Better coordination of care for patients and their families has long been seen as a core feature of good quality primary care (Kringos et al., Reference Kringos, Boerma, van der Zee, Groenewegen and Kringos2012). Defined by the WHO as a proactive approach to bringing together care professionals and providers to meet the health needs of the population and to ensure that they receive integrated, person-focused care across various settings (WHO, 2018a). Care coordination’s importance has grown with the increasing rates of people experiencing chronic and multiple health conditions (EU Companion Report, 2017). Gaps in care coordination are associated with lower satisfaction for patients and families, unnecessary healthcare expenditure, and a higher risk of patients experiencing medical errors (Penm et al., Reference Penm, MacKinnon, Strakowski, Ying and Doty2017). Care coordination occurs at multiple levels – by the patient and the family themselves, within one organization (ie, multiple professionals within a single community health provider or general practice), and between multiple organizations through vertical (ie, sequential) and/or horizontal (ie, parallel) provider networks (Sheaff et al., Reference Sheaff, Halliday, Øvretveit, Byng, Exworthy, Peckham and Asthana2015). Care coordination is a core component of case management which involves proactive case finding, assessment and care planning for at-risk populations. Such comprehensive programs can improve patient-centered care, facilitate self-management of long-term conditions, enable greater independence, and enhance patient satisfaction (Buja et al., Reference Buja, Francesconi, Bellini, Barletta, Girardi, Braga and Damiani2020). The impact of selfcare management on healthcare expenditure and long-term survival rates is less clear, but greater in systems without a strong tradition of multidisciplinary primary care teams and where there is involvement of social workers alongside healthcare professionals (Stokes et al., Reference Stokes, Panagioti, Alam, Checkland, Cheraghi-Sohi and Bower2015).

An important recent development for care coordination has been the recognition that traditional primary care services must better integrate with agencies that address people’s broader needs (National Academies of Sciences, 2019; Miller et al., Reference Miller, Brown and Mangan2016). This includes agencies that provide ‘social care’ services such as support with personal care (eg, washing and dressing), managing tasks of daily living (eg, shopping and cooking), and support for family carers (eg, respite breaks). Social care can be provided in a variety of settings including someone’s family home, designated supported housing schemes, and nursing homes with 24-hour care on site. Care coordination for particular populations encompasses services relating to the broader determinants of health and well-being including employment, education, domestic violence, and substance misuse. This can include access to charitable resources and voluntary support through social prescribing or community navigator schemes (Tew et al., Reference Tew, Duggal, Carr, Ercolani, Glasby, Kinghorn, Miller, Newbigging, Tanner and Afentou2019).

There is no-one approach to care coordination that works effectively in every context for all populations (Øvretveit, Reference Øvretveit2011). Achieving successful coordination is multi-factorial and requires planned system-level activity within and between organizations (Valentijn et al., Reference Valentijn, Boesveld, Van der Klauw, Ruwaard, Struijs, Molema, Bruijnzeels and Vrijhoef2015). Common enablers include defined referral pathways and processes, information agreements regarding patient assessment and plans, shared electronic records and technological facilitators, self-management training and support for patients and their families, and relevant quality management tools to improve coordination processes (Rijken et al., Reference Rijken, Struckmann, der Heide, Hujala, Barbabella, van Ginneken and Schellevis2017; WHO, 2018a). For those with the most complex needs due to health or social circumstances, the identification of a named coordinator can be beneficial. The coordinator can provide continuity for the patient and their family, advocate for their interests in multi-agency meetings, ensure that there is good communication between professionals, and facilitate regular reviews of the care provided (Goodwin et al., Reference Goodwin, Sonala, Thiel and Kodner2013). Depending on the needs, workload pressures, and scope of their professional role, the coordinator may be an existing member of their multidisciplinary team who has an established relationship with the patient and their family (Penm et al., Reference Penm, MacKinnon, Strakowski, Ying and Doty2017). However, in other circumstances it is better for a professional who is introduced with the specific remit of coordination to ensure that they have the necessary capacity, connections, and authority to negotiate with other services. Professionals will need training and ongoing learning opportunities to ensure they develop and maintain the required competencies for coordination. This may be best achieved through interprofessional education to enable information sharing and experience of working closely with those from different disciplines (Miller et al., Reference Miller, Scherpbier, van Amsterdam, Guedes and Pype2019).