Primary care in Europe: Can we
make it fit for the future?
Supported by:
12 December 2013
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Components of primary care
Primary care lies between self-care and hospital (or specialist care) and
fulfils a range of functions:
• prevention and screening
• assessment of undifferentiated symptoms
• diagnosis
• triage and onward referral
• care coordination for people with long-term conditions
• treatment of episodic illness
• provision of palliative care
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The model traditionally used to deliver primary care in many
countries has not changed significantly for many years
Very often primary care:
•
is delivered by small independent practices with limited access to a wider
multidisciplinary team
•
is based on a model of inflexible and short appointment slots only available from
Monday to Friday within normal working hours
•
is unable to offer telephone, email, skype or other modern access to medical and
nursing advice
•
has inadequate diagnostic support
•
is insufficiently connected to specialists, community-based services (e.g.
pharmacy) and other resources that could help it function more effectively.
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Number of doctors per 1,000 population in Europe
1. Data include not only doctors providing
direct care to patients, but also those
working in the health sector as
managers, educators, researchers, etc.
(adding another 5 to 10% of doctors).
2. Data refer to all doctors who are
licensed to practice.
Source: Adapted from Organisation for
Economic Co-operation and
Development (OECD) indicators: Health
at a Glance 2011. Health workforce.
Medical Doctors.
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Relative provision of GPs, specialists and other doctors
in Europe
1. Specialists include paediatricians, obstetricians/gynaecologists, psychiatrists, medical specialists and surgical specialists.
2. Other doctors include interns/residents if not reported in the field in which they are training, and doctors not elsewhere classified.
Source: Adapted from OECD indicators: Health at a Glance 2011. Health workforce. Medical Doctors.
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Public expenditure on health as a percentage of GDP in EU
member states (2008)
Source: Adapted from European Commission (2010). OECD health data 2010, Eurostat data and WHO Health for All database. EU, EA, EU15.
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Gatekeeping from primary to specialist care
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Source: European Commission (2010). Adapted from Paris and others (2010) Health Systems Institutional Characteristics: A survey
of 29 OECD countries. Health working paper No. 50, OECD 2010 + Country Fiches.
Multiple factors influencing primary care supply and demand
Lack of access to
social care
New providers/supply
induced demand
Rising prevalence of
chronic disease and
multi-morbidity
Rising patient
expectations
Primary
care
Ageing populations
New technologies and
treatments
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Categories of primary care organisation
Organisational
type
Structure and
process
Value base
Service focus
Location
(examples)
Endpoint
Countries
(examples)
Extended general
practice
Simple, partnership
Normative
Registered patient
list
Health centre
Patient
Finland, Portugal,
Greece
Managed care
enterprise
Complex,
stakeholder
Calculative
Target groups
Physicians’
group
User
Ireland, Italy,
England
Reformed polyclinic
Coalition, divisional
Commercial
Medical conditions
Multi-specialist
clinic
Client
Macedonian and
Czech Republics
Medical cabinet
Self-employed,
independent
Professional
Maintenance
Municipal
premises
Attendees
Hungary
District health system
Hierarchic,
administrative
Executive
Public health
improvement
General hospital
Populations
N/A
Community
development agency
Association, network
Affiliative
Local populations
Health stations
Citizen
N/A
Franchised outreach
Quasi-institutional,
virtual
Remunerative
Payers
Private, hospital
premises
Customer
Poland
For a more detailed explanation of the terms used in this table, see Meads (2009) ‘The organisation of primary care in Europe: Part 1
Trends – position paper of the European Forum for Primary Care’, Quality in Primary Care 17, 133–43.
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New models of primary care emerging in Europe (1)
Zorg In Ontwikkeling (ZIO), The Netherlands
•
General practice network of 90 GPs covering 170,000 population
•
Physiotherapists, dieticians and nurses also members of the network
•
Multidisciplinary focus on delivery of coordinated chronic care
•
Disease management programmes
•
Integrated payments for a year of care for long-term conditions
•
Members receive education, quality systems, IT support and real
estate development
•
Piloting population-based budgets.
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New models of primary care emerging in Europe (2)
Brahehälsan, Sweden
•
Two private primary care clinics established by doctors within the
Praktikertjänst company
•
Enabled by legislation opening up the primary care market in
Sweden
•
12 doctors, 10 nurses, allied health professionals, nurse assistants,
clerical staff, social worker
•
Serves 12,600 people and has an electronic patient record
•
In a network with specialist outpatient services and the local hospital.
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New models of primary care emerging in Europe (3)
Community Health Centre Botermarkt, Ghent, Belgium
•
Not-for-profit, multidisciplinary, primary health centre in a deprived area of Ghent, for
6,000 patients from over 70 countries
•
Financed through integrated needs-based mixed capitation
•
9 FTE physicians (including 2 FTE trainees), 4.5 FTE nurses (including 1 FTE nurse
assistant) and 8 FTE other staff including health promoters, dieticians, tobaccologist,
dentists and ancillary staff
•
There is an electronic and interdisciplinary record
•
Aims to deliver integrated primary health care: prevention; curative care; palliative care;
rehabilitative care; and health promotion
•
Works within philosophy of community-oriented primary care and co-designs care
objectives with patients who have multi-morbidity in the framework of goal-oriented
care, and tailors services accordingly.
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New models of primary care emerging in Europe (4)
Whitstable Medical Practice, UK
•
NHS general practice and community integrated health care for 34,000 patients
•
19 doctors, 34 nurses and 130 other staff
•
Diagnostics, outpatient services, day surgery, screening services and minor injury
unit
•
Plans to integrate social care
•
Electronic patient record
•
Wide range of preventive health care, screening, exercise programmes, smoking
cessation
•
Redesigned care pathways as basis for developing new primary care services:
long-term condition management; urgent care; elective care and diagnostics;
community hospital.
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New models of primary care emerging in Europe (5)
Vitality Partnership, Birmingham, UK
•
Super-partnership formed though mergers of small practices; now has 50,000
patients across seven sites
•
27 doctors, 23 nurses and 137 employed staff
•
A single IT system and integrated electronic patient record
•
Aims to deliver high-quality, population-based primary care with
in-house provision of specialist services
•
Specialist services include dermatology, rheumatology, orthopaedics and
diagnostics
•
New career options for doctors and nurses; strong focus on organisational
development.
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Primary care that is fit for the future needs to be:
• Comprehensive
And sustainable in terms of:
• Person-centred
• Finance
• Population-oriented
• Workforce
• Coordinated
• Public trust
• Accessible
• Fit with wider health system
• Safe and high quality
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Design principles for primary care provision
• Securing the Future of General Practice1 proposes a set of
design principles to be used when determining primary care
provision. These can:
o address the pressures facing GPs
o ensure that both the needs and priorities of patients are met
o ensure that primary care will be fit for the future
• The principles can be applied when reviewing and redesigning
primary care provision for a given population or community
• Some of the principles are focused on the provision of clinical
services, and others on organisation.
1. Smith J, Holder H, Edwards N, Maybin J, Parker H, Rosen R and Walsh N (2013) Securing the Future of General Practice: New
models of primary care. Nuffield Trust.
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Re-designing primary care: design principles
Access and continuity
Early access to expertise
Tailored encounters
Accessible
diagnostics
Continuity and
coordination
Anticipatory care and
population health
Generalism and
specialism
Patients and populations
Goal-oriented care
Multidisciplinary
working
Information and outcomes
Single electronic record
Quality and outcomes
Use community assets
Management and accountability
Organisation and
management
Contract for value
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Links between payment systems, integration and
accountability
The case studies suggest that primary care systems will need to:
• be larger
• have access to a wider range of professionals as part of the
team or working alongside them
• offer a better organised out-of-hours service
• provide better continuity to those patients that need it most
Models that follow this logic will be better placed to go beyond
traditional primary care and develop more ‘integrated care’. This
creates the opportunity for them to take on risk sharing and
capitation budgets.
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Value-based payment continuum (UnitedHealth Group)
Source: UnitedHealth Group
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Conclusion
•
Primary care remains a key part the health system; the challenge is how it
can respond to the growing demands of increasingly complex and older
patients
•
New models of care organisation are emerging to meet these challenges
•
Greater scale, more standardisation, the inclusion of specialist expertise and
bringing in social care and other community services are key starting points
•
Leadership from within the profession is vital
•
When the design principles are combined, fundamental changes to the
organisation and delivery of primary care become necessary, including the
linking together of practices in federations, networks or merged partnerships
in order to increase their scale, scope and organisational capacity
•
This will need to be done while preserving the local small-scale points of
access to care that are valued highly by patients.
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12 December 2013
© Nuffield Trust