International Journal of Integrated Care, 1 September 2001 - ISSN 1568-4156
Book review
Primary care: balancing health needs, services and technology
Barbara Starfield
New York: Oxford University Press, 1998, pp 448,
ISBN 0 19 512543 6
Judith Smith, Senior Lecturer, Health Services Management Centre, University of Birmingham

This book is widely acknowledged to be one of the key texts within primary health care policy, written by an author who has written extensively about primary care within health care systems and in its international context. In the preface to the book, the author sets out her intention as being “to help readers understand the role of primary care as an organising focus of health systems, to provide the available scientific evidence on its utility, and to help further its development and growth”. She suggests that her audience is primary care practitioners, educators of primary care practitioners, researchers, policy-makers, and consumers of health services. The key questions, therefore, are: the extent to which the author achieves her aim; and given the focus of this journal, what the book has to offer these audiences in terms of an understanding of the place of primary care as a force for achieving a greater degree of integrated care.

The book is divided into five main sections: primary care and health; primary care practice; accountability in primary care; patients and populations for primary care; and health policy and primary care.

In the first section (primary care and health), the author locates primary care firmly in its wider context as part of the whole spectrum of health and health care, a spectrum where the wider determinants of health are of greater significance than health services in relation to actual health outcomes. She re-states her strongly-held belief that primary care is the crucial foundation of a health care system, and defines the key features of primary care as being: the first point entry to a health care system; the provider of person-focused (not disease-oriented) care over time; the deliverer of care for all but the most uncommon conditions; and the part of the system that integrates or co-ordinates care provided elsewhere or by others.

Starfield sets out a framework for measuring primary care based on her core primary care functions and a review of the literature related to assessment of primary care. In doing so, she shows that countries with stronger primary care do better in terms of both health outcomes and costs. This focus on setting out criteria and approaches to measuring aspects of primary care and health systems is central to the whole book, and as such makes the book of particular relevance to anyone engaged in primary care or wider health systems research.

In the second section of the book (primary care practice), the author describes primary care in the USA and the United Kingdom. The main emphasis is however on the former, with the UK being used as a comparison, although Starfield at this point stops short of drawing out the rather obvious uncomfortable lessons for the USA in terms of costs in relation to health outcomes. However, in chapter 6, an analysis of different funding methods for primary care is set out, along with a summary of key international health system reform themes. This is used as a basis for assessing the role of primary care within US managed care and within health reform more generally, with the author cautioning against the de-professionalising of doctors within managed care, and the various risks associated with reforms based on competitive or market models.

The third section of the book (accountability in primary care) is organised according to Starfield's four key features of primary care. She looks first of all at the concept of the ‘gatekeeper’ and considers how access and accessibility to primary care may be measured, once again offering important pointers to those concerned with researching health systems. In the context of integrated care, her comment that “longitudinality is associated with a variety of benefits, including less use of services, better preventive care, better recognition of patients' problems, less hospitalizations, and lower total costs” (pp 163–164) underlines the importance of this book to current debates about the overall management and co-ordination of care for individuals. Comprehensiveness is likewise presented as a benefit of a primary care based system, and tools for assessing this are described in some detail. Co-ordination or ‘putting it all together’ as the chapter is sub-titled, is acknowledged to be difficult, and frequently poorly done. The author makes a plea for more systematic studies of the reasons for deficiencies related to co-ordination of care, along with the identification of methods to overcome them.

In considering ‘patients and populations’, the fourth section of the book provides an overview of research and policy issues related to the assessment of quality in primary care, followed by a review of international work carried out to evaluate this sector of health care. Valuable pointers are offered, including the different perspectives to be considered such as those of the patient, the community, and the educator.

The concluding section of the book (health policy and primary care), draws together the lessons of the earlier sections, grounding them in a comparative analysis of primary care systems in twelve countries. Starfield emphasises the association between a strong primary care orientation of a health system and positive health indicators, although she notes that primary care based systems tend to do less well in terms of patient satisfaction. She also sets out a menu of primary care research needs, and, lest the policy-makers think they can escape her shrewd analysis, a set of international policy challenges related to primary care.

To answer my initial question, this book does indeed help the reader to understand the role of primary care as an organising focus for health systems, using scientific evidence in the process and setting out ideas about the future research and development of this area of health care. The particular strengths of this book are the clear enthusiasm for primary care as the fulcrum of a properly integrated health care system, clearly rooted in a thorough and detailed analysis of the available literature. A wealth of pointers are given in relation to the practice, study, teaching and policy of primary care, and it is a book which all those who work in and alongside primary care should have close to hand as a point of crucial reference.

If I have one criticism, it is perhaps that the book seeks to be overly comprehensive, trying to fulfil the multiple objectives of analysing the role and functions of primary care, making international comparisons, considering the evaluation and research of primary care, highlighting policy issues, and so on. Now that primary care is firmly established as the cornerstone of health care systems, and with an ever-increasing body of supporting literature, perhaps there is room for this book to form the basis of a series of shorter, more focused books. This one criticism should not, however, detract from the fact that the book stands as an indispensible, thoroughly researched, and eminently accessible text for all those who are interested in the development of integrated health care systems firmly based on robust primary care.