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Primary Care |
Delivering Primary Care
PROLOGUE: Comparisons between the health care in the United States, Canada, and the United Kingdom tend to be dominated by an emphasis on the differences between public and private systems of management and financing. In these two illuminating studies of primary care in Canada and the United Kingdom, the focus is on delivery systems; the emphasis that emerges is on the similarity of the challenge that faces all three systems to improve coordination of acute, primary, and community-based care.
U.S. readers might be surprised to learn from Brian Hutchison, Julia Abelson, and John Lavis at Ontario’s McMaster University that Canada’s federal system—often misleadingly described as "single-payer"—was founded on a political compromise with doctors, much as the U.S. Medicare program was, and that government’s power to dictate how the health system works is in many ways as limited in Canada as it is across the border. As a result, efforts to foster integration through the provincial system have repeatedly run afoul of physician autonomy and been frustrated, just as most private-sector integration efforts have foundered in the United States.
Further light is shed both on the problem of optimizing delivery system arrangements and on the limited role of government in Canada by comparison with Britain’s truly national system. In 1999 the National Health Service (NHS) laid on a system of mandatory primary care groups (PCGs) that link primary care doctors, community nurses, and other health and social service professionals in a system of nearly 500 "IPA-like" networks with responsibility for coordinating services to assigned populations of 50,000 to 250,000 patients each.
How well the mandate can be implemented depends on physician acceptance, information infrastructure, and other factors that the NHS may not be able to control. But the paper by Andrew Bindman, Jonathan Weiner, and Azeem Majeed has immediate relevance for students of U.S. health policy who are interested in translating population health goals into performance standards for health care organizations. Notwithstanding differences in financing and governance, the two systems have this essential challenge in common.
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