However, there has been a traditional hospital disinterest in PHC activities.
The interest of acute care hospitals has been centering on development of quality secondary and tertiary care facilities and programmes. Hospitals have viewed their role as delivery of curative services and not in early intervention, reduced mortality, prevention of disease or health education which is the basis of most PHL programmes. However, there is now a growing realisation of the role hospitals can play in PHC.
(ii) PHC as Entry Point into Hospitals:
In large cities there is marked tendency to bypass primary care facilities in preference for the teaching hospital resulting in primary and routine care workload on specialised services, defeating the special role of such hospitals. Opening PHC units within the premises as the first entry point to the hospital for such routine direct cases will reduce avoidable routine workload for specialised outpatient departments (OPD). Teaching hospitals, as a back-up support to PHC, can start screening units within their premises for patient’s coming directly for routine medical care as part of PHC. These PHC units can also be utilised as laboratories for experimentation with different models of primary health care after epidemiological research, besides setting examples for hospitals at district level and others.
(iii) The Role of General Practitioners (GPs):
The position of GPs in providing primary health care and the potential for integrating their activities with other health personnel is being increasingly recognised.
A community primary health care programme (CHP) started by a small urban hospital can establish a strong relationship between the CHP and the hospital, with GPs helping to run the primary health care centre. Coordination between these CHPs and the hospital at the appropriate level with open channels of communication can keep the programme going well. However, it is also feared that an excellent programme can fail if it lacks constant drive to maintain a certain level of standard and if consistent supervision is lacking. One of the difficult problems to solve is keeping the hospital focussed on primary care. It is natural for a small facility to want to keep growing bigger and more sophisticated.
(iv) Some PHC Related Experiences Abroad:
In USA a changing relationship is emerging between hospitals and PHCs. A shift from cost reimbursement to hospitals to the fixed fee payment schedules for specific diagnostic related groups (DRGs) has forced hospitals in USA to cut costs and resulted in reduced length of stay, reduced admissions, reduced utilisation of ancillary services, and large increases in outpatient procedures. The decreasing demand for inpatient acute care has thus resulted in overcapacity of hospital beds.
In some areas many hospitals are only 50 per cent occupied. Another factor that has focused the attention of hospitals on PHC is the rapid popularity of health maintenance organisations (HMOs) in the USA. HMOs are interested in primary and not secondary health care. They are interested in health education, prevention, screening and immunisation programme, early detection and diagnosis, “wellness” and other primary care activities. “They (HMOs) carry out these programmes with a variety of health professionals including midwives, physician, assistants, nurse practitioners, registered nurses and other allied health professionals.
Sweden, whose health care was based totally on hospitals, has realised the need for primary health care. The expansion of primary health care implied an increase in the number of general practitioners, district nurses and other types of staff to get over the necessity of too many patients being admitted for inpatient care just because the appropriate services were not available in day care or other institutions. The Swedish concept envisage that patient who need continuity in their relationship with doctors and those with multidimensional problems should be better off with well- functioning primary care services.
Finland, one of the pioneers in primary health care implementation in Europe, presently spends about 55 per cent of its health expenditure on preventive and ambulatory services and 41 per cent hospitals. Sweden has adopted the “lowest level of care” concept.
(v) Development of a PHC Policy by Each Hospital:
To decide the scope and extent of the PHC to be provided by it, every hospital will have first to prepare a PHC policy and strategy. The policy statement should outline the essential points to be included and then list the actions needed ensure putting the policy into effect. The hospital’s effective involvement in PHC would require a much broader vision than cure alone, and therefore, a broader range of action. What restricts the effective involvement of hospitals is that few hospital professionals are trained and inclined to think in this communitywide context, so that a substantial change of attitude is needed to accept the centrality of PHC as the basis of hospital involvement. The hospital may either assume a lead role in organising PHC for its population or play a purely supportive role.
With its concentration of health professionals, a hospital is in a position to effectively supervise and monitor PHC work, in addition to providing primary care through the hospital- staffed mobile and outreach clinics. The secondary care role of the hospital would support PHC by providing referral from primary health services, technical and logistic support and acting as a centre for education and training of PHC- oriented manpower.
(vi) Referral Function:
1. Organising a two way referral system from mobile and outreach clinics to the hospital and referral back with reports for follow-up 2. Backing up the referral system with medical records 3. Organising visits of hospital specialists to outreach clinics 4. Carry out training and reinforcing skills at PHC workers by visiting specialists 5.
Giving preferences to patients referred from PHC centres for specialist clinics and for admissions.
(vii) Support Function:
1. Providing logistics support in respect of equipment, materials, drugs and other supplies 2.
Reinforcing diagnostic capabilities of PHC workers and outreach clinics 3. Providing transport for referrals and outreach services 4. Making hospitals facilities available for training and retraining of PHC workers.