Jewell addresses an important issue in questioning the benefits and risks of closer integration between the primary and acute care sectors.1 In a desperate search to explain poor health system performance, many commentators have seized upon the lack of vertical integration in the UK as A Problem Needing a Solution.
At face value, they are correct. Of course it is essential that from the patient's perspective care is delivered in as seamless a way as is possible. However, I wonder if those who call for closer integration really understand the functions of primary and secondary care. Certainly, there is little evidence that Honigsbaum,2 really grasped the role of the generalist, although earlier commentators, such as Margaret Stevens,3 seemed to have more insight into the issues. I suspect that advocates of integration see the two sectors as existing on a single continuum, with primary care at the ‘simple task’ end of the production line and hospital-based care at the ‘complex task’ end. This world view dictates that closer integration is a desirable task and an easy one to undertake.
I think that this stance represents a fundamental misunderstanding of the complementarity of the two sectors. Primary care is a philosophically, structurally and functionally distinct part of the health system. The differences are not historical accidents, or examples of professional protectionism. On the contrary, the emphasis that a primary care practitioner places on generalism, holism, coordination and the capacity to deal with uncertainty, benefits patients and the health system in the same way as the specialised, reductionist and episodic modus operandi of the hospital practitioner.
For everyone's benefit, let's celebrate the differences, rather than attempt to eliminate them.
- © British Journal of General Practice, 2004.
