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10 UNIVERSAL HEALTH CARE for a particular group of people. Examples include geriatricians, pediatri- cians, and gynecologists. In Canada and most European countries such as Italy and the United Kingdom, the law ensures that patients require a referral from a primary care practitioner before they can proceed to secondary care for tests and treatment. Accident and emergency services, instead, are usually provided at any level without the need for a referral. In the United Kingdom, for example, any resident wanting access to one of the government-funded secondary care facilities must be enrolled with a local GP, who serves as a gatekeeper overseeing all referrals and ambulatory care. GPs are fully accountable for the quality of care, and this pyramid-like structure with primary care at its base is needed to contain the budget for medical resources and the costs faced by the government to pay for more specialized personnel and facilities. On the other hand, this issue is particularly severe in Africa and other non-industrialized countries such as Thailand. Here all types of medi- cal professionals are usually very scarce, and district hospitals represent a centralized unit where all the technical and medical resources are con- centrated. The hospital cannot then afford to offer any form of direct access and must be saved for referrals of all patients who cannot be treated with the means available at the first contact level. AmericaÊs system, instead, is a much more dispersed model where patients might enter the health care system at any level they please. The emphasis given to specialty medicine and secondary care accounts for a system whose topography resembles a diamond rather than the traditional pyramid with primary care at its base. In America, patients frequently end up taking their symptoms directly to the specialist of their choosing. As a consequence, only 13% of physicians in the United States are general or family practitioners, less than half than in the United Kingdom where 28% of all physicians are GPs. Although many specialists such as general inter- nists or pediatricians take on the role of PCP to their patients, the percent- age of visits that Americans make to office-based physicians are still very low. Of nearly 956 million visits in 2008, only 51.3% were to PCPs, while it has been estimated that in the United Kingdom over 90% of all contacts with the National Health Service (NHS) occur in general practice. Long-Term and Post-Acute Care LTC includes all medical and nonmedical services provided to assist an individual affected by a disability, a chronic illness, or a long-term condition that makes him or her unable to care for himself or herself for an extended period of time. Rather than just treatment, LTC focuses on maximizing the patientÊs quality of life and meeting all his needs and can