BackgroundAccess is central to the performance of health care systems around the world. However, access to health care remains a complex notion as exemplified in the variety of interpretations of the concept across authors. The aim of this paper is to suggest a conceptualisation of access to health care describing broad dimensions and determinants that integrate demand and supply-side-factors and enabling the operationalisation of access to health care all along the process of obtaining care and benefiting from the services.MethodsA synthesis of the published literature on the conceptualisation of access has been performed. The most cited frameworks served as a basis to develop a revised conceptual framework.ResultsHere, we view access as the opportunity to identify healthcare needs, to seek healthcare services, to reach, to obtain or use health care services, and to actually have a need for services fulfilled. We conceptualise five dimensions of accessibility: 1) Approachability; 2) Acceptability; 3) Availability and accommodation; 4) Affordability; 5) Appropriateness. In this framework, five corresponding abilities of populations interact with the dimensions of accessibility to generate access. Five corollary dimensions of abilities include: 1) Ability to perceive; 2) Ability to seek; 3) Ability to reach; 4) Ability to pay; and 5) Ability to engage.ConclusionsThis paper explains the comprehensiveness and dynamic nature of this conceptualisation of access to care and identifies relevant determinants that can have an impact on access from a multilevel perspective where factors related to health systems, institutions, organisations and providers are considered with factors at the individual, household, community, and population levels.

PURPOSE In 2004, we undertook a consultation with Canadian primary health care experts to defi ne the attributes that should be evaluated in predominant and proposed models of primary health care in the Canadian context. METHOD Twenty persons considered to be experts in primary health care or recommended by at least 2 peers responded to an electronic Delphi process. The expert group was balanced between clinicians (principally family physicians and nurses), academics, and decision makers from all regions in Canada. In 4 iterative rounds, participants were asked to propose and modify operational defi nitions. Each round incorporated the feedback from the previous round until consensus was achieved on most attributes, with a fi nal consensus process in a face-to-face meeting with some of the experts. RESULTSOperational defi nitions were developed and are proposed for 25 attributes; only 5 rate as specifi c to primary care. Consensus on some was achieved early (relational continuity, coordination-continuity, family-centeredness, advocacy, cultural sensitivity, clinical information management, and quality improvement process). The defi nitions of other attributes were refi ned over time to increase their precision and reduce overlap between concepts (accessibility, quality of care, interpersonal communication, community orientation, comprehensiveness, multidisciplinary team, responsiveness, integration).CONCLUSION This description of primary care attributes in measurable terms provides an evaluation lexicon to assess initiatives to renew primary health care and serves as a guide for instrument selection. Med;5:336-344. DOI: 10.1370/afm.682. Ann Fam INTRODUCTIONH ealth systems based on a strong primary health care system are more effective and effi cient than those centered on specialty and tertiary care.1 In Canada, various national and provincial commissions on health care [2][3][4][5][6][7][8] concluded that strengthening and expanding primary health care will meet Canadians' needs for prompt access to comprehensive evidence-based services. Major initiatives have also been undertaken in New Zealand and the United Kingdom to strengthen primary health care. 9,10 As health systems worldwide engage in evaluation efforts to assess the impacts of primary health care renewal initiatives, there is a critical need to provide evaluation frameworks and tools to facilitate these efforts.An important starting point for evaluation is an operational defi nition of the dimension being evaluated. An operational defi nition is a description of a concept in measurable terms. It is used to remove ambiguity, to serve as a guide for the selection of measurement tools, and to reduce the likelihood of disparate results between different data collections. 337 AT T R IBU T ES O F PR IM A RY HE A LT H C A R Edevelop a common lexicon of operational defi nitions of attributes to be evaluated in predominant and emerging models of primary health care in Canada, but many of these defi nitions will be relevant to primary health care mode...

Rationale, aims, and objectives: Unwarranted clinical variation is a topic of heightened interest in health care systems around the world. While there are many publications and reports on clinical variation, few studies are conceptually grounded in a theoretical model. This study describes the empirical foundations of the field and proposes an analytic framework. Method: Structured construct mapping of published empirical studies which explicitly address unwarranted clinical variation.Results: A total of 190 studies were classified in terms of three key dimensions: perspective (assessing variation across geographical areas or across providers); criteria for assessment (measuring absolute variation against a standard, or relative variation within a comparator group); and object of analysis (using process, structure/resource, or outcome metrics). Conclusion:Consideration of the results of the mapping exercise-together with a review of adjustment, explanatory and stratification variables, and the factors associated with residual variation-informed the development of an analytic framework.This framework highlights the role that agency and motivation, evidence and judgement, and personal and organizational capacity play in clinical decision making and reveals key facets that distinguish warranted from unwarranted clinical variation.From a measurement perspective, it underlines the need for careful consideration of attribution, aggregation, models of care, and temporality in any assessment.

ContextA key aim of reforms to primary health care (PHC) in many countries has been to enhance interprofessional teamwork. However, the impact of these changes on practitioners has not been well understood.ObjectiveTo assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in PHC practices.DesignCollaborative synthesis of 12 mixed methods studies.SettingPrimary care practices undergoing transformational change in three countries: Australia, Canada, and the USA, including three Canadian provinces (Alberta, Ontario, and Quebec).MethodsWe conducted a synthesis and secondary analysis of 12 qualitative and quantitative studies conducted by the authors in order to understand the impacts and how they were influenced by local context.ResultsThere was a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions. These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups.ConclusionThe variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level. The same characteristic could have both positive and negative influence on different aspects (eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice). Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level.

COVID-19 has affected every healthcare system around the world. In New South Wales (NSW), Australia, healthcare activity was subdued in the first half of 2020, as healthcare-seeking behaviour changed and service provision was modified to manage system capacity • The disruption COVID-19 has caused to provision of healthcare may have both positive and negative health consequences. Ongoing monitoring of these potential consequences will be required