Changing the face of primary care
Modern health-care systems were established around 1950 with the goal of addressing acute bouts of ill health that either kill their host or recede almost entirely.
The face of the system was the family physician, always available to see patients, and the hospital gradually emerged as the core institution where high-risk situations were dealt with by more and more specialized services.
Fast forward 50 years and the needs of the population have changed dramatically.
Whereas acute, often infectious, diseases were the main source of ill health, chronic conditions and then general frailty have come to characterize today’s health problems.
A chronic condition is a health problem that does not go away, at least not quickly, but, at the same time, it does not kill its host (again, not instantly). The role of health care is therefore not to fix the issue and move on to another patient, but rather to monitor, control and stabilize the problem, entering into a long-term relationship with the patient.
Because chronic conditions don’t go away rapidly, they can accumulate in the same body: as they get older, patients in this new epidemiologic age suffer from multiple conditions.
This poses a threat to the hyperspecialization of the health-care system, in particular of hospitals: to treat a patient with multiple conditions, one has to know this very patient and the course of their health state, as much as (or even more than) be an expert in each of the separate conditions.
A population with many individuals older than 80 is a population with a higher risk of frailty (in 2023, 1.9 million residents of Canada were 80 and older). Frailty is not linked to a specific organ failure or identified disease, it is a state of vulnerability: mild events that would leave a non-frail individual totally untouched can trigger a downward spiral of functional impairment in a frail individual.
A frail individual requires even more monitoring and proactive intervention to stabilize health than an individual with multiple chronic conditions.
Needs have changed and will continue to change, but our healthcare system is still organized around the family physician as the main point of contact and the hospital as the heroic fixer of last resort.
Both family physicians and hospitals are experts in assessing the risks and potential consequences of specific health events (things that happen to patients).
Such expertise is based on knowledge of dozens or hundreds of similar “cases,” where a case is the sequence of a trigger event and some health state. The knowledge needed in the case of a patient with multiple conditions or a frail patient is quite different: it is a high level of expertise in that very patient, an ability to detect minute signs that this patient is not in their normal state, that they are at risk.
Such knowledge requires seeing perhaps fewer patients, but knowing each patient very well.
We will always need the eventbased expertise of course, but a reorganization of the health-care system should allow for the recognition of the pre-eminence of the patient-based expertise and knowledge.
This means that the face of primary care should no longer be the family physician or not even a team led by the family physician. Their expertise is needed, but should be summoned only when needed.
Who, then, should be the face of primary care, the main point of entry to the health-care system and the captain of the team?
Obviously, the provider engaged in a long-term relationship with the patient, who can monitor, detect minute signs of risk, proactively intervene, hire the family physician or hospital as a consultant if need be and act as an advocate for the patient.
That a personal-service worker or a nurse should be the captain of the health team runs contrary to our strong feeling that academic knowledge should be preeminent. But this is what the need of the population requires, nevertheless.