What is Primary Care? International Forum on Quality and Safety in Healthcare, 2014 Martin Marshall Professor Healthcare Improvement, UCL Lead, Improvement Science London

'Surgeon and Apothecary. Prescriptions and family medicines accurately compounded. Teeth extracted at one shilling each. Women attended in labour, two shillings and sixpence each. Patent medicines and perfumery. Best London pickles. Fish sauces. Bear's grease. Soda water. Ginger beer. Lemonade. Congreve's matches and Warren's blackening.‘ Apothecary shop window, Manchester, UK, 1842

Implications of breaking down the boundaries between primary and secondary care The evidence-based benefits of a primary care orientation for health systems may not be realised The roles and responsibilities of primary care practitioners become less clear Specialised biomedicine dominates

Defining Primary Care Definitions have focused on: 1.Restrictive practices and job demarcation between generalists and specialists 2.Descriptions of what Primary Care Practitioners do 3.Dimensions that are easily measured 4.Understanding the philosophy of generalist practice

What Primary Care Practitioners do first point of access provision of comprehensive care whole-person orientation commitment to families and communities provide continuity of care act as advocates on behalf of patients deal with co-morbidity Which of these can be validly measured?

The mystery of general practice “General practice is the art of dealing with people who insist on being ill with scant regard to everything that doctors are taught at medical school” Marshall Marinker, 1995

The mystery of general practice The specialism of diseases without names The specialty of the renaissance (wo)man Artists who play with science Specialists in biography The job of stopping people from drowning Health professionals who help people to make sense of their lives Health professionals who witness their patient’s suffering

A different perspective: What does primary care contribute to health systems? Primary care is the part of the health system where: 1.ambiguity and uncertainty are tolerated 2.the interface between professional and self care is shifted 3.the up-stream determinants of health are understood and acted upon 4.the tensions between different dimensions of quality are managed