• Open Access

Primary Healthcare: People, Practice, Place

By Valorie A. Crooks and Gavin J. Andrews . Published by Ashgate , 2009 . Hardcover : 272 pages , ISBN: 978-0754672470 . RRP $145.00

Reviewed by Victoria J. Palmer

Applied Ethicist, Primary Care Research Unit, The Department of General Practice, The University of Melbourne, Victoria

Crooks and Andrews's Primary Healthcare: People, Practice, Place sits within the geographies of health series and is a first of its kind text. The series aims to introduce a largely under-addressed subject (geography) in primary healthcare (PHC) research to examine risk, representation, meaning, inequality, power, culture and difference including health mapping and modelling. While geographic information systems (GIS) have been employed in health services research for mapping disparities in access and equity, the goal of this book is to explore geography beyond solely space to geography as place. There are few publications that examine this relationship between geography and PHC.

The publication is timely given the increased prominence of PHC for the World Health Organisation (WHO), the focus on PHC reforms in Australia and other international trends. Wiles and Rosenberg (page 75) cover some of the important changes currently affecting PHC: the drift away from single practice locations to group practice locations; the use of regional organisations as mechanisms for planning and sometimes funding PHC (for example, primary care trusts in the UK); and, replacing (especially physicians) and attracting workers to rural and remote locations. It is fair to suggest these are globally shared by many PHC systems regardless of local contextual differences.

Indeed, PHC holds a unique place in the global health landscape. It is defined not only around the broad collection of health practitioners providing services, but also according ‘to a more holistic approach to healthcare that is beyond a biomedical model’ (Hanlon, page 43). In its early inception, PHC was seen as a mechanism by which to empower communities and individuals to facilitate health and well-being, this theme is present within many chapters.

The holistic focus and sentiment of PHC is reinforced across the collection, but the book has not escaped the ongoing tension of when and where to apply the term ‘primary care’ (PC) or ‘primary healthcare’ (PHC). To address this, the editors have distinguished between the two, defining PC as the delivery of first contact, medical care, and PHC to include secondary and tertiary sectors (Crooks and Andrews, page 7). Unfortunately the breadth of PHC continues to place limitations on how well it can be defined. Although Crooks and Andrews emphasise a broader view of PHC because of the patient journey throughout a landscape for example from clinic or hospital to home, the question remains – which providers are responsible for co-ordination of patient care? Moreover, how will healthcare systems be designed to facilitate integration across such broad services and settings?

There are 22 contributors to this four-part book. Contributors cover topics related to the current geography research agenda in healthcare (Andrews and Crooks), how the distribution of PHC resources of space are integral to realising PHC's vision (Hanlon), how equity is shaped by geography including not only distance but topography, population density and socio-economic vulnerability (Schuurman). Gold examines healthcare clinics in Peru, Agarwal describes the role of family medicine, Lupum et al., explore the place of nursing in PHC, Barnett and Barnett examine the reinvention of PHC in New Zealand, Hollenberg and Bourgeault introduce the changing landscape of PHC with the increasing role of complementary, alternative and traditional medicines. The clinic environment and its implications for practice is also explored (Crooks & Agarwal and Kearns & Neuwelt), home is examined as an essential place of care (Yantzi & Skinner), and PHC for difficult to reach populations in Britain is covered (Conradson & Moon).

While the topics are broad, geographical representation is limited. Obviously an edited collection cannot cover every system of PHC. Absent voices include Australian or US perspectives on the matters at hand where there is vigorous debate about the future of PHC. That said, strengths to the collection include, taking account of space and place in PHC, and geography as an inclusion of culture and other dynamics.

At the conclusion I am still left with a sense that there is a lack of consensus about when, where and how to apply the definition of PHC or PC. Moreover, when does community participation and capacity building shift from the community development arena to everyday healthcare? The editors escape this issue by an inclusive definition of PHC that includes both health and social care that includes access to food, shelter and education. Yet again, how is this coordinated and integrated to provide a whole system of healthcare? I would think that those who would most benefit from the text will have an interest in the geographic aspects of healthcare including equity, access and community.