AFHTO Policy Positions

Valuing comprehensive primary care: The Starfield Principles

There is a compelling association between comprehensive primary care and system efficiency and effectiveness. The lifelong work of the late Barbara Starfield observed that an investment in primary care was associated with improved system quality, equity and efficiency (reduced cost)[i],[ii],[iii] ,[iv]. In British Columbia this efficiency was quantified by Marcus Hollander. The total cost of care was measured for the sickest patients. Patients without close alignment to primary care had a system cost of $30,000/patients/year. Patients with close alignment to primary care had a system cost of $12,000/patients/year[v].

The value of comprehensive primary care comes from the focus on the whole person, in their family and community context, over their lifetime. It is based on long-term, trusting relationships. This must be reflected when measuring performance in comprehensive primary care.

In collaboration with members and research partners, AFHTO has been developing a system of measurement, based on the principles revealed through Dr. Starfield’s work.  Its objective is to enable teams delivering comprehensive primary care to optimize their performance and to evaluate the benefits over time. Using indicators from Health Quality Ontario’s Primary Care Performance Measurement Framework, it measures quality, capacity and total health system cost of care for patients.

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[i] Shi L, Starfield B, Kennedy BP, Kawachi I. Income inequality, primary care, and health indicators. J Fam Pract. 48 (1999), 275–84.
[ii] Starfield B. Family medicine should shape reform, not vice versa. Fam Pract Man. May 28, 2009; Global health, equity, and primary care. J Am Board Fam Med. 20(6) (2007), 511–13; Is US health really the best in the world? JAMA. 284(4) (2000), 483–4; Research in general practice: co-morbidity, referrals, and the roles of general practitioners and specialists. SEMERGEN.  29(Suppl 1) (2003), 7–16, Appendix D.
[iii] Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy. 60 (2002), 201–18.
[iv] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly. 83(3) (2005), 457–502.
[v] Increasing Value for Money in the Canadian Healthcare System, Hollander et al. Healthcare Quarterly Vol 12 No. 4 2009