This is a fascinating book discussing the geographies of health and health care, and specifically in primary health care (PHC), encompassing both national and international perspectives, for example, research undertaken in Peru (Chapter. 6) and Canada (Chapter 4). The editors present a compilation of papers with the overarching aim to inform how we think geographically about PHC, how we construct accounts of why place matters, for example, the relationship between service location and access. The word ‘geographical’ is used as an umbrella term to identify research on health and health care, which emphasises place and/or space, or directly examines phenomena, for example, environments, areas (eg, urban), regions, etc. The editors contend that it is only in recent years that the discipline of human geography has moved from examining patterns of general health service to a broader approach that considers specifically the landscape of PHC.
The book begins with the editors presenting two chapters defining critically differing perspectives of PHC and geographies of health. These form an essential backdrop to the book. The chapters illustrate wide international variation in how PHC is understood and interpreted, and geographers’ interest in the influence of these variations on health and access to health care. These are detailed critiques that make for interesting reading and are essential if the reader is to understand the arguments presented in the subsequent chapters. The editors frame their enquiry by identifying three key principles of PHC that echo core geographic concepts:
• access – access to quality care and decision making on service provision;
• equity – fair and just distribution of resources; and
• community – community-orientated PHC, for example, client participation.
The differing geographical perspectives present a historical summary on the emergence of health geography, providing an interesting discussion on, for example, geographical perspectives in nursing research that conceptualise areas such as community in community health nursing (Bender et al., Reference Bender, Clune and Guruge2007). A central tenant of the book is that health geography needs broad foci to encompass the many variants in PHC practice, not a narrow focus on physician-led or medically orientated health care.
The main book is divided into four parts: ‘practice and delivery’, ‘people’, ‘places and settings’ and concludes with ‘agenda setting’. Part 1, ‘practice and delivery’, presents four papers critically discussing access and utilisation of PHC services. Hanlon (Chapter 3) begins by arguing that a broad approach to PHC, involving a range of practitioners and a population-based approach to identify and target unmet needs, is known to have beneficial outcomes, but that such reform is slow. Future research utilising a geographical perspective is argued as a way of re-examining issues of access and use in PHC, and identifying barriers to reform. The theme of access continues in Schurman’s chapter (Chapter 4), providing a more in-depth analysis of prominent influences (population size, distance and socio-economic status) drawing upon the example of rural communities in British Columbia (BC), Canada. Findings from data analysis of ‘geographic information systems’ (GIS) in BC illustrate the inequity of access to health care for rural communities, with positive health outcomes further compounded by lower socio-economic status. The detailed findings illustrate how objective data could inform the equitable distribution of healthcare services. The organisation and structure of PHC, and equitable access, are further explored by drawing upon a concept of ‘geographic scale’ (p. 75). Geographic scale is described by the authors as a ‘slippery concept’ (p. 89). At its basic level, a means of examining how, for example, size of a general practice, organisation of government service planning (eg, the regional level) impact on access and use, through to more abstract ideas of the relationships between local, national, international and global provision and the impact of these relationships. These are complex ideas, but presented in an accessible way.
Part two, exploring ‘people’, provides a range of enquiries from a general discussion on the role of the General Practitioner drawing upon key components (resource, clinician, patient–doctor relationship), through to a more radical view of the role of nurses and complementary/alternative therapies in PHC. All draw upon geographical principles. The chapter on nurses observes that they are not commonly acknowledged as PHC practitioners, or that they acknowledge themselves as providing PHC. Are nurses working in PHC so hidden? It may be so from the Canadian perspective this work is based upon, but can this be attributed in the UK? The chapter presents an interesting discussion on the parallels between PHC and nursing practice and asserts that the role of a nurse is not fully realised because of the dominance of physician-led care and the biomedical model in the organisation of healthcare services. The authors assert a familiar call that nurses need ‘to articulate how their positions are configured’ (p. 143) and advocate a geographical perspective that considers the ‘intersections between nurses, place and PHC’ (p. 143) as a way forward. The chapter on complementary/alternative and traditional therapies (CAM/TM) in PHC draws upon a case study of an integrated healthcare centre providing both biomedical care and CAM/TM or non-biomedical care. The authors argue that CAM/TM should be an integrated part of PHC services. Their case study clearly indicates patient demand for these types of therapies, but there is no evaluative work on the outcome of providing these types of services. This is unfortunate.
The final section explores the theme of ‘places and settings’ moving from a micro perspective of PHC embodied in ‘the clinic’ through to the macro focusing on ‘community participation’ and ‘outreach services’. This forms a logical sequencing of the impact of the clinic environment on consultations (eg, degrees of ‘busyness’, ‘privacy’), to arguing the need to move beyond ‘the clinic’ and broaden the construction of place in PHC, using examples of NHS walking in centres (WICs), homeless services and the role of informal carers. The descriptions of a clinical environment reiterate current understanding on activities that enhance and disrupt consultations, but form an important backdrop on the need to broaden PHC provision beyond the health centre. The exploration of services for hard to reach groups provides a fascinating analysis of WICs, intended for such groups, but mainly used by the ‘affluent and busy’ and not the excluded, and then characteristics of successful services specifically for homeless people identifying barriers to access and impact of their removal, for example, registration. A rural setting in Canada forms the setting for a study on the role of healthcare providers that focuses on informal carers for adults or children with chronic conditions, who play an essential role in the provision of PHC in very rural areas where distance and sparse services inhibit access. Informal carers are viewed by default as partners in the continuum of provision of PHC, for example, managing, monitoring and responding to change. Even so, the carers consider their role has a ‘lack of legitimacy’ (p. 231). The authors rightly argue that ‘understanding care provision in the home in terms of vulnerability and sustainability is a prerequisite for the development of informed PHC policy’ (p. 233).
This book aimed to explore ‘why place matters’ (p. 1) by interrogating the ‘landscapes that inform the…nature and principles of PHC and…shape how this care is both delivered and received’ (p. 261). The final section on ‘agenda setting’ summarises the extent to which this has been achieved, asserting that the book provides a ‘solid foundation to further develop the geographies of PHC.’ (p. 272), and identifies future research areas, notably the need to engage with the continuum and continuity of care across time and space. The book provides diverse discussions that reflect much of the complexity of providing PHC, both from national and international perspectives. A major gap is the near absence of discussion on the role of social care in the community, even though there is an underlying theme of the need to adopt a broader model of health that moves beyond a medical model. An exception is Chapter 14 ‘on the street’ (part 3) that clearly asserts the need to integrate health and social care to meet the needs of homeless people. The research and professional opinions presented in the book all provide snapshot explorations of a single point in time. Given that chronic disease management forms a major and growing component of PHC, the authors quite rightly identify the need for geographies of health to focus on the continuum and continuity of PHC.
