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Levels of care

In this series of articles, medical students from across the country will discuss a range of topics from medical ethics to the NHS to public health to medical conditions to clinical governance.

The NHS, as one of the biggest employers in the world, is a complex machine defined by many layers of resource provision that aim to work together to seamlessly deliver the best and most comprehensive care to patients.

A key phrase is that of ‘levels of care’- these are namely Primary, Secondary and Tertiary care.

Similar to primary, secondary and tertiary colours, levels of care reflect not only the stage in the patient journey at which patients might see particular healthcare professionals, but also the level of complexity of health problems that can be found within each level for the practicing physician.

Primary care, also referred to as General Practice (GP) or Family Medicine, is the most frequently used gateway to the health system. ‘Primary’ suggests it’s the first port of call for patients to attend with health concerns, after which the GP may either escalate to higher levels of care or manage that patient in the community with medications, advice and/or reassurance. Primary care is the backbone of the NHS as this is where patients are ‘triaged’ and referred to the appropriate services, making sure services are used appropriately, efficiently, economically and as safely as possible for the patient.

Secondary care refers to hospital-based care. These can be split into acute emergency services (such as A+E) or elective services (these are planned services, such as cataract operations, knee replacement operations, etc.)

Tertiary care is more specialist than primary and secondary care, meaning there may only be one or two places in each region, or even the country, that provides particular services. This can be because there may be fewer people trained in delivering those services or because they require specialist equipment that may be expensive, require specialist training and are not readily available everywhere. Examples include neurosurgery, transplant services and secure forensic mental health services.

Ceilings of care

Another similar and equally important phrase to levels of care is that of ‘ceilings of care’. This is a phrase heard particularly in Intensive and Palliative care. It refers to the maximum level of care which the patient is set to receive, and this is often a complex and sensitive decision reached between the patient, their family and the healthcare team responsible for the patient. An in-depth example of this may be a frail patient with advanced cancer, for whom further active chemotherapy treatment has been deemed to cause more harm than good given the intense side effects of chemotherapy. This patient is therefore said to be ‘palliative’ and approaching the end of life. If this patient presents with a chest infection for which they require admission to hospital, a ceiling of care may likely be set. In this instance, it may be appropriate to set the ‘ceiling’ to ward-based care only. This means that if the patient becomes more unwell during their hospital stay, they will not be escalated to the intensive care unit where other patients may be taken if they deteriorate on the ward. This is because their chances of survival may be very low and subjecting the patient to further painful, undignified interventions for minimal gain in their quality or quantity of life would be unethical.

In summary, levels of care can mean primary, secondary or tertiary that differ depending on the specialism of service provision required as well as when a patient might require those services (e.g. patients typically are seen in primary care before secondary care before tertiary care). Levels of care can also reflect key ethical concepts of end of life care that require tough decisions to be made in the best interest of the patients’ physical and mental wellbeing.