• primary care
• patient choice
• internet

Primary care is changing. No longer is it confined exclusively to the GP surgery or health centre, and nor are the routine contacts restricted to “office hours”. There have been many recent consumer driven changes to the delivery of health care in the UK. “Walk in” centres—NHS and private—provide a service to consumers who find themselves unable to access GP surgeries.¹ Many people, for instance, may commute long distances to work and find their GP opening hours are too restrictive. On the other end of the social spectrum, homeless patients often prefer to access “drop in centres”² where the services are better orientated to their needs. Another development is the UK telephone and online service, NHS Direct, which offers patients both information and advice—for many it is now their first contact with the health service.³

But the most dramatic change to primary care lies in consumer health informatics, or ehealth.⁴ Consumers can now access an unparalleled wealth of health information via the internet. The National electronic Library for Health (www.nelh.nhs.uk) is a UK resource available to both staff and patients which provides links to a host of other related sites. Some such as NHS Direct online (www.nhsdirect.nhs.uk) use the interactivity of the internet to allow consumers to receive information and advice tailored to their own specific health needs.⁵ Another ehealth application—interactive decision explorers (iDEXs)—assists patients in making decisions on difficult issues such as benign prostatic hyperplasia treatments⁶ or hormone replacement therapy.⁷ Exciting opportunities are offered by multimedia and broadband technology: consumers will increasingly be able to access digital audiovisual information rapidly. DIPEx (www.dipex.org), for instance, is a website that already uses this to great effect—patients present their own personal experiences of cancer.⁸

The opportunities for consumers will advance further with the development of the “single electronic health record” which is being developed by a number of countries and organisations for their patients.⁹ The obvious benefits for a large complex organisation such as the UK NHS are consistency and availability of information throughout the system. But who will own this information? It is likely that consumers will demand ownership—and why not? After all, they already control their financial and other personal details. Armed with their single electronic health record, consumers will be able to exercise an unprecedented degree of choice. Moving between GP surgeries and “walk in” centres will become far easier and conversations with telephone health services will become much more meaningful. Consumers will also be able to use their electronic record to engage far more productively with interactive ehealth applications; these, in turn, will become much more sophisticated.

“… primary care must be defined from the consumer’s perspective . . .”

In this changing field, the quality and safety debate must also develop and adapt quickly. Maxwell’s criteria, for instance, contained six elements: effectiveness, efficiency, equity, access, acceptability and appropriateness.¹⁰ All are relevant to the newer elements of primary care. The issue of social equity in accessing health informatics—the “digital divide”—has come to the forefront of public debate. Nonetheless, reflecting the need for change, others have expanded on these criteria: Moss, for instance, suggested that respect, choice, and availability of information should be included.¹¹ In the case of health informatics, and particularly healthcare websites, there has been a proliferation of quality measures; 51 were recently identified—none had been validated.¹² In a sense this merely reflects the diversity and dynamism of ehealth. On the other hand, the potential for misinformation and patient harm is clearly a serious concern; the European Union recently defined a set of quality criteria for health related websites in terms of transparency and honesty, authority, privacy and data protection, updating of information, accountability, and accessibility.¹³

Before developing and applying these quality criteria, however, we must first be clear about what is now understood by the term “primary care”. The definitions of primary care we have at present are outdated. They are usually service led¹⁴ and frequently draw on the differences and tensions between primary and secondary care.¹⁵ In these cherished definitions, primary care is centred on the all encompassing local GP centre¹⁶ where care is delivered in the context of a reformist public health and political agenda.¹⁷ Clearly, it is time to move on. However painful to the medical perspective, primary care must be defined from the consumer’s perspective—a consumer who will increasingly seek health advice from an ever diversifying range of sources.

But, crucially, the consumer will also demand quality and safety from this newly conceptualised “primary care”. The quality criteria can be specified once a new definition of primary care has been agreed. We therefore propose a new definition of primary care: “A consumer’s initial health care interaction—human or electronic”.