Primary care in the driver's seat? Organisational reform in European primary care
International Journal of Integrated Care, 25 April 2007 - ISSN 1568-4156
Book review
Primary care in the driver's seat? Organisational reform in European primary care
Edited by Richard B. Saltman, Ana Rico, Wienke Boerma
Open University Press, Maidenhead: 2006, pp 251,
ISBN 978 0 335 21365 8
Han van Oosterbos, former CEO of the Almere Health Care Organisation, The Netherlands

Is primary care capable of taking a dominant role in running the whole health care system? This challenging question is what makes this book interesting and takes the debate one step ahead in the discussion of solely strengthening primary care, however important. In doing so, it affects the heart of integrated care; how to improve the clinical coherence and coordination that in the end leads to a patient led health service.

Although in a lot of countries primary care is still in its infancy, this question is a concern to them as well as to the countries with a more developed primary care in that it affects the discussion concerning the institutional design of primary care and in fact the whole healthcare system.

The editors, referring to primary care as a variety of disciplines directly accessible for unselected health problems, and drawing on a broad range of studies and perspectives from different countries, have succeeded in painting a fascinating picture of the process of organisational change in European primary care.

Key words in this process are: coordination and integration, or how to manage the network.

In mapping the landscape of primary care in Europe, the main conclusion is that even in countries with a gate-keeping GP, neither extended primary care nor general practice at this moment serve as a powerful basis of their healthcare systems. Putting primary care behind the wheel, the first step needed is to approach primary care as an organisation. However, this leaves us with the question of how to develop a good working balance between the managerial needs of such an organisation and the clinical care to their patients by the primary care professionals without becoming a state agent.

The book provides the reader with various models of coordinating primary care in different countries with different health systems (tax-funded, social insurance systems, transitional systems). In doing so, the editors have chosen 3 angles: changing institutional arrangements, changing working arrangements, changing quality standards.

Each angle consists of a set of chapters that demonstrates the shifting framework of primary care across Europe on topics such as: the role of primary care professionals, the impact of primary care purchasing, the evolving public-private mix, the influence of payments systems on quality and performance of primary care, the role of primary care education, the necessity of ICT in primary care.

The strong side of the book is that it provides the reader who is interested in strengthening primary care, notwithstanding the healthcare system he or she is working in, with state of the art information and suggestions for strategies one can use in the debate to reform primary care in one's own country.

Although this book should be compulsory literature for policy makers and health managers, it is also of interest for primary care professionals and students, especially by the lot of vignettes in which pictures are drawn elaborating on concrete examples in various countries.

Throughout the book the editors consequently stress the importance of involving other primary care professions into the process of strengthening primary care. However, the book regrettably focuses primarily on developments in general practice. The reason for this probably is that there has been less research into the developments of other primary care providers such as community nursing, home help, pharmacists, social work, midwives, mother and child care. Perhaps the next status report could incorporate more studies on the process of change within the other primary care disciplines.

In pursuing a coordinated and integrated primary care organisation as a strong and influential base for the whole health care system, the aims are high. They concern not only an important shift in the system but also a fundamental change of our health care the systems, because we should always keep in mind that the ultimate goal is not a primary care led service but a patient led health service.