What are the advantages and disadvantages of restructuring a health care system to be more focused on primary
Healthcare Contracts Limitations Essay
When students obtain academic awards in the health industry that they do not deserve, they may emerge unfit for professional practice. This paper explores the challenges posed by academic misconduct in public-facing health fields, such as nursing and medicine.
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Specifically, the paper explores contract cheating, where students employ a third party or ghostwriter to complete assessed work. The problem appears more crucial in health than some other academic disciplines, since here fitness for practice is important and human lives may be at stake. The paper argues about the importance of academic integrity in health through multiple examples. This includes showcasing media cases where medical professionals have been put in positions which their skills did not warrant and giving three specific examples of attempts by students to cheat that have been detected online. The examples demonstrate that such contract cheating starts before students arrive at university. This misconduct continues throughout their academic career up to postgraduate level. The overall findings in this field support the view that contract cheating is habitual and repeated regularly by some students. Several sources are used to show that contract cheating in health is amongst the most popular subjects that students cheat on. Other examples show that original essays and assessments can be purchased by students for affordable prices. These essays will not be detected as unoriginal by Turnitin. The paper concludes by arguing that increased academic pressure is needed to change the wider health culture that is affording contract cheating.Healthcare Contracts Limitations Essay
This is a Health Evidence Network (HEN) synthesis report on the advantages and disadvantages of restructuring
a health care system to be more focused on primary care services.
The available evidence demonstrates some advantages for health systems that rely relatively more on primary
health care and general practice in comparison with systems more based on specialist care in terms of better
population health outcomes, improved equity, access and continuity and lower cost.
This report is HEN’s response to a question from a decision-maker. It provides a synthesis of the best available
evidence, including a summary of the main findings and policy options related to the issue.
HEN, initiated and coordinated by the WHO Regional Office for Europe, is an information service for public
health and health care decision-makers in the WHO European Region. Other interested parties might also benefit
from HEN.
This HEN evidence report is a commissioned work and the contents are the responsibility of the authors. They
do not necessarily reflect the official policies of WHO/Europe. The reports were subjected to international
review, managed by the HEN team.
When referencing this report, please use the following attribution:
Atun R (2004) What are the advantages and disadvantages of restructuring a health care system to
be more focused on primary care services? Copenhagen, WHO Regional Office for Europe (Health Healthcare Contracts Limitations Essay
Evidence Network report; http://www.euro.who.int/document/e82997.pdf, accessed 20 January
2004). Keywords
DELIVERY OF HEALTH CARE – ORGANIZATION
AND ADMINISTRATION
PRIMARY HEALTH CARE
EVALUATION STUDIES
QUALITY OF HEALTH CARE
PATIENT SATISFACTION
HEALTH SERVICES ACCESSIBILITY
COST-BENEFIT ANALYSIS
DECISION SUPPORT TECHNIQUES
EUROPE
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The World Health Organization does not warrant that the information contained in this publication is complete and
correct and shall not be liable for any damages incurred as a result of its use. The views expressed by authors or
editors do not necessarily represent the decisions or the stated policy of the World Health Organization.Healthcare Contracts Limitations Essay
Globally, governments are searching for ways to improve equity, efficiency, effectiveness, and
responsiveness of their health systems. The WHO World Health Report identifies many countries that
fall short of their performance potential (1). There is no agreement on optimum structures, content,
and ways to deliver cost-effective services to achieve health gain for the population.
In recent years there has been an acceptance of the role of primary health care (PHC) in providing cost
effective health care (2, 3, 4). However, the advantages and disadvantages of health care systems that
rely on medical specialists versus the systems that rely more on general practitioners and primary
health care have not been systematically reviewed or a case for primary health care firmly established.
This paper assesses the empirical evidence for them through a review of studies published in the
period 1980-2003. A discussion of the generalizability of findings follows. It also explores definitional
issues related to primary health care.
In this review, the terms primary health care, primary care and general practice are used
interchangeably. Generally, primary care and general practice refer to primary medical care, which in
the WHO definition of primary health care form only a part of a greater set of aims and activities, as
described in the next section.
This study was inherently complex due to a number of factors.
• There are varied definitions of the scope and role of general practice, primary care, primary
health care and specialists. For instance, a primary care team can vary from a community nurse,
a feldsher or rural general practitioner to a multidisciplinary team of up to 30, comprising
specialist nurses, managers, support staff, family medicine and other primary care specialists.
• The boundaries of primary and secondary care differ among and within countries, making
comparison and generalizability of studies particularly challenging.
• Organizational structures in many countries are changing, giving way to integrated institutions
comprising primary and secondary care.
• In many health systems, services traditionally provided by secondary care specialists are now
the responsibility of the primary care team, making a definite distinction between secondary and
primary care specialists difficult.Healthcare Contracts Limitations Essay
Sources for this review
The review is based on a detailed search using key sources of literature including: PubMed; Medline;
EMBASE; Social Science Citation Index (BIDSS); National Centre for Reviews and Dissemination
(UK); DARE; CRD Reports; NHS Economic Evaluation Database; Agency for Health Care Policy
and Research; ScHARR; World Bank Registers, World Health Organization and the Cochrane
Library.
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What are the advantages and disadvantages of restructuring a health care system to be more focused on primary
care services?
WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004
The search was focused to identify evidence in the following areas:
• international comparisons of primary care and specialist led care and their effect on equity of
access, health outcomes, and patient satisfaction
• the relationship between access to primary care and health outcomes, patient satisfaction and
cost
• continuity of care and health outcomes
• substitution of primary care for hospital care
• shared primary care and secondary care being as good as secondary (specialist) care only
• comparison of the effectiveness of GPs (primary care physicians) and hospital specialists.
The review follows validated methods for critical appraisal (5, 6), and includes studies with the
following designs: systematic reviews, randomized controlled trials (RCTs), quasi-experiments,
evaluative studies and case control studies. Leading editorials focusing on the concept and trends are
also included. Language limitations of the author meant that only publications in English and Spanish
were reviewed. Studies in other languages, descriptive studies, and case studies with no evaluation
criteria or clear purpose were excluded. In the search, 1300 documents were retrieved. Of these, 256
were judged to be relevant for the study and 111 papers were considered to be of sufficient quality for
detailed review and inclusion in the assessment.
While the author attempted to systematically weigh the evidence, it should be made clear that due to
time constraints, this is not a formal systematic review.
Defining primary and specialist care
Specialist care is defined as those services delivered by narrow specialists, usually in hospital or in an
ambulatory setting and those not delivered in primary care. Defining primary care is fraught with
difficulties. An attempt to do so in the United States yielded no fewer than 92 definitions (7).
Similarly, in the European region, the definition of PHC varies by country (8, 9). Primary care
definitions can be considered in terms of concept, level, content of services, process and team Healthcare Contracts Limitations Essay
membership. A detailed discussion on this is given in Annex 1.
Findings from research and other evidence
Population health and aggregate health expenditure
A recent study assessing the contribution of primary care systems to a variety of health outcomes in 18
wealthy OECD countries over three decades revealed that the strength of a country’s primary care
system was negatively associated with population health outcomes such as all-cause mortality, allcause premature mortality, and cause-specific premature mortality from major respiratory and
cardiovascular diseases (10). Stronger primary care meant better health outcomes. This relationship
was significant even while controlling for determinants of population health at macro-level (GDP per
capita, total physicians per one thousand population, percent of elderly) and micro-level (average
number of ambulatory care visits, per capita income, alcohol and tobacco consumption). Furthermore,
PHC characteristics such as geographic regulation, longitudinality, coordination, and community
orientation were associated with improved population health. This reinforces findings of an earlier
international comparison involving 11 developed countries which demonstrated that a higher primary
care orientation of a health system was more likely to produce better population health outcomes, at
lower cost, and with greater user satisfaction (11).
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What are the advantages and disadvantages of restructuring a health care system to be more focused on primary
care services?
WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004
In a comparative study in the United States, Shi demonstrated that availability of primary care
physicians correlated positively to favourable health outcomes, including age-adjusted and
standardized overall mortality, mortality associated with cancer and heart disease, neonatal mortality,
and life expectancy (12), whereas absence of a primary care source was found to be the most
important factor in determining poor health (13). In contrast, health systems dominated by specialists,
such as that of the United States, have higher total health care costs and reduced access to health care
by the vulnerable populations (14, 15, 16). The high cost is attributed to proportionately low numbers
of primary care physicians and consequent impairment of the gate-keeping function (17, 18). Areas of
the United States with lower rates of primary care physicians per population have higher Medicare
(federal health insurance mainly for people 65 years of age or older) expenditures (19).Healthcare Contracts Limitations Essay
Primary health care, when compared with secondary care, is a lower cost environment as services
delivered by specialists are higher cost due to a tendency to use expensive technology and orientation
to curative rather than preventive medicine (18).
In developing countries, systematic international data supporting a strong correlation between
increased PHC spending or access and improved health outcomes is not strong (20), due to the
inherent difficulty of disaggregating socio-economic and health system interventions.
Equity and access
In low-income countries, evidence shows that expenditure on PHC is more pro-poor than aggregate
expenditure that includes hospitals, and has a desirable distributive impact benefiting the poorer
segment of the population proportionately more than the richer segment (20). Studies from developed
countries demonstrate that an orientation towards a specialist-based system enforces inequity in access
(21). In contrast, there is general agreement that expenditure on primary care improves equity (22).
Greater investment in primary care increases access to care with associated lower mortality and
morbidity (23). Conversely, a reduction in access to PHC results in a worsening health status (24, 25).
Quality and efficiency of care
There is a paucity of rigorous studies evaluating the quality and cost effectiveness of care delivered in
the primary care setting or by general practitioners (26). A systematic review of the quality of clinical
care in general practice concluded: “The published research in the field presents an incomplete picture
of the quality of clinical care in terms of its methodological rigour and comprehensiveness” and that
“Judgements about quality of care tend to be based on fragmented information” (27).
A substantial number of well-designed studies exist comparing care delivered by general practitioners
to that by specialists. These show no significant difference in quality of care and health outcome for
care delivered by general practitioners even when substituted for secondary care specialists (28).
Primary care physicians are more likely than specialists to provide continuity and comprehensive care
resulting in improved health outcomes (29). Improved access to primary care physicians and their
gate-keeping function have added benefits such as less hospitalization (30, 31, 32), less utilization of
specialist and emergency centres (33, 34), and less chance of being subjected to inappropriate health
interventions (35). In contrast, when direct access to specialists is possible without a controlling
mechanism by primary care physicians, the quality of care, as measured by appropriateness, worsens
and health care costs increase (36). Healthcare Contracts Limitations Essay Furthermore, evidence from a systematic review suggests that
broadening access to primary care can reduce demand for expensive, specialist-led hospital care (37).
Not all studies support the evidence that the gate-keeping function of primary care improves patterns
of secondary care and hospital use (38). Some studies in selected areas of care at the primarysecondary interface show that shifting care previously undertaken by specialists does not necessarily
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What are the advantages and disadvantages of restructuring a health care system to be more focused on primary
care services?
WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004
result in reduced demand for specialist or secondary care services (39, 40, 41, 42), and some confirm
the advantages of specialists for hospital inpatient care (43, 44, 45, 46). This advantage is not
observed for outpatient care (47, 48, 49).
The empirical evidence of what care can be readily shifted from specialist-led secondary care to PHC
is limited (50). Some studies analysing substitution of selected services (for instance for hypertension
and asthma) from secondary to primary care showed this shift to be more cost-effective, although
others found contrasting or ambiguous results. For instance, a comparative analysis of quality and cost
of depression treatment by primary care physicians and specialists shows the latter to be more
effective but more costly (51).
Cost effectiveness
Implicit in the literature on primary care is that hospital care is inappropriate as a first resort for and
therefore primary care is necessarily a ´good` substitute. However, this assumption must be supported
by empirical evidence. In low-income settings, the cost effectiveness of PHC compared to other health
programmes is confirmed by a review (52). This reinforces World Bank findings that selected primary
care activities, such as infant and child health, nutrition programmes, immunization and oral
hydration, appeared as “good buys” compared to hospital care (53), and that interventions deliverable
in primary care facilities could avert a large proportion of deaths (54). The Bamako Initiative in Benin
and Guinea demonstrates that even in resource-poor settings it is possible to implement and sustain
basic PHC services (55).
Shifting care across specialist-general practice and secondary-primary care boundaries is possible and
has been shown to be cost effective without an adverse affect on outcomes. For instance, general
practitioner-led hospitals in Norway provided health care at lower cost compared to alternative modes
of care, due to averted hospital costs (56). United Kingdom studies confirm that GP hospitals save
costs by reducing referrals and admissions to higher-cost general hospitals staffed by specialists (57,Healthcare Contracts Limitations Essay
58, 59). Care delivered by general practitioners, compared to hospital specialists, in hospital-based
accident and emergency departments was shown to be more cost effective with lower use of diagnostic
investigations, lower referral rates to secondary services, lower prescription levels, and no significant
difference in patient satisfaction or health outcomes (60, 61, 62).
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Patient satisfaction
A comparison of 10 Western countries suggested higher user satisfaction levels for health systems
based on a strong primary care system if the influence of expenses on the health care was controlled.
The United Kingdom was an exception despite having a health system with a strong primary care
orientation and relatively low total health expenditure (63).
The Euro barometer survey of citizens of 15 European Union Member States shows that Denmark,
which has a very strong primary care system with 24-hour, 7-day access to primary care, has the
highest public satisfaction with health care (64), attributed to the value placed on the accessibility of
primary care delivered by general practitioners (65). However, patient satisfaction with primary care
and general practitioners is strongly influenced by the mode of care delivery, physician style,
availability of out-of-hours care, a named physician, continuity of care and provision of routine
screening (66, 67, 68, 69).
In the US system, gate-keeping exercised by primary care physicians preventing direct patient access
to specialist care led to patient dissatisfaction (70).
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What are the advantages and disadvantages of restructuring a health care system to be more focused on primary
care services?
WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004
Generalizability
Studies in the review are predominantly from the United States European countries such as the United
Kingdom, Netherlands and Nordic countries and low-income countries in Africa. Research from
transition countries, middle-income countries and Latin America is lacking.Healthcare Contracts Limitations Essay
The review revealed a paucity of high quality studies comparing advantages and disadvantages of
PHC and specialist care in Europe; comparative studies tended to be from the United States. There
were few cost-effectiveness analyses comprehensively evaluating services provided in PHC. These
were RCTs examining segments of particular interventions rather than comprehensive or integrated
management of the problem in question.
The extent to which the findings can be readily generalized to support policy recommendations is open
to debate, as the available evidence comes from a number of different countries, with a variety of
different health system structures, organization, financing and delivery modes. It is difficult to control
for these factors. Changes observed may be attributable to factors such as health system financing or
physician behaviour rather than where and by whom the care is delivered. Disaggregating the impact
of these factors from the domain, health professional, or delivery mode is difficult.
Transferring evidence or care models from one setting to another without a clear understanding of the
context and health system dynamics can produce unintended consequences. Caution should be
exercised before embarking on reforms that favour primary care-based systems and where shifts across
boundaries are concerned without clearly defining policy objectives and identifying the evidence base
to support them. Funding agencies and the research community need to be encouraged to undertake
rigorous national and transnational comparative studies to improve the knowledge and evidence bases
to inform policy decisions.
Discussion
The success of health systems in tapping the existing potential or making appropriate structural
changes to enable shifts from expensive to more cost-effective alternative sub-sectors such as PHC is
by no means universal. The extent of importance attached to primary care varies from country to
country. Despite the evidence for primary care, resource allocation in most countries still favours
hospitals and specialist care. This is partly due to perceptions about what PHC is, what it has to offer
(71), and its development as a control function to reduce costs or access to secondary care (72, 73),Healthcare Contracts Limitations Essay
rather than its positive contribution to health gain. This explains the paradox of the attractiveness of
primary care on empirical grounds and its lack of appeal to national policy-makers and healthcare
professionals, who see it as a low-grade activity with little effect on mortality and serious morbidity
and a predominant role in triage of access to hospitals.
This inefficiency in resource allocation has implications for equity and efficiency. It may explain why
increased total public spending for health has not improved equity of access and outcomes
proportionately and has had less impact on average health status than expected (74, 75).
Given the right incentives, in any health system, there is the real opportunity to expand provision of
medical services in a primary care setting (76). The lack of identity poses problems for the proponents
and funding agencies who believe that primary care is necessary (77). Policy-makers need to be made
aware of the concept of primary care and what it has to offer. This will require investment for
advocacy and marketing activities to communicate the benefits of primary care to health professionals,
policy-makers and the public.
The role of primary care should not be defined in isolation but in relation to the constituents of the
health system. Primary and secondary care, generalist and specialist, all have important roles in the
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What are the advantages and disadvantages of restructuring a health care system to be more focused on primary
care services?
WHO Regional Office for Europe’s Health Evidence Network (HEN)
January 2004
health system. Healthcare Contracts Limitations Essay
