Primary care in Europe: Can we make it fit for the future?

Primary care in Europe: Can we make it fit for the future? European Health Summit 2013: Delegate briefing January 2013 Supported by:

2 The second European Health Summit (Euro-Summit), hosted by the Nuffield Trust and supported by KPMG, is being held in Brussels on 28 and 29 January 2013. It will consider the future of primary care in Europe in the context of challenges such as financial constraints and an ageing population, and opportunities that include technological and workforce innovation. The Euro-Summit will provide an opportunity to examine different models of primary care and identify those that offer the best promise of delivering primary care that is fit for the future. This delegate briefing introduces some of the issues that will be explored at the Euro-Summit, and is intended to raise questions and stimulate discussion. The briefing presents the aims of the Euro- Summit and sets out a definition of primary care that will underpin discussions. It briefly describes the diversity of existing primary care systems across Europe, and presents the case for changing the way primary care is organised and delivered in future. The briefing also sets out the core questions to be explored, with a particular focus on the development of primary care systems that can meet future health and financial challenges within the specific political and policy context of individual European countries. Aims of the Euro-Summit 2013 To explore how and why primary care organisation and delivery needs to change, and the factors driving this. To examine the changing scope and role of primary care in different European health systems and identify the essential characteristics of primary care systems that are fit for the future. Using case studies from different European countries, to review the extent to which different models of primary care are already achieving these characteristics and importantly how they are doing this. To enable high-level debate among a group of senior policy-makers, practitioners and academics about the ways in which effective reform of primary care delivery and organisation might be accelerated (including policy, institutional, financial and managerial mechanisms). The first European Health Summit, hosted by the Nuffield Trust and supported by KPMG, was held in January 2012 on the topic of payment reform. Materials with information about the discussions are available at: www.nuffieldtrust.org.uk/eurosummit/2012 Find out more online at: www.nuffieldtrust.org.uk/euro-summit/2013

3 The nature of primary care Strong and effective primary care is seen as a key part of a high-performing health care system because of its ability to improve health outcomes and contain costs (Starfield and others, 2005). A report published by the World Health Organization (WHO) Regional Office for Europe suggests that the strength of a country s primary care system is associated with lower mortality and premature mortality rates, especially from major respiratory and cardiovascular diseases (Atun, 2004). The availability of primary health care is also associated with greater patient satisfaction and reduced aggregate health care spending (when compared to countries with an orientation towards a specialist-based system), with delivery of services in primary health care rather than specialist services shown to have no adverse effects on the quality of care or patient outcomes (Atun, 2004). The distinction between primary care as a set of services focused on social development as defined in the Alma Ata Declaration (WHO, 1978) and primary care as a level of health care organisation has been well rehearsed (for example, Tarimo and Webster, 1994). The Euro-Summit will focus on the latter concept of primary care, namely as first-line medical and health care services in which generalist clinicians (doctors, nurses, pharmacists or other community health workers) act as a first point of contact for undifferentiated health problems. This recognises primary care as those services that typically lie between self-care and hospital/specialist care, and fulfil a range of functions including: prevention and screening; assessment of undifferentiated symptoms; diagnosis; triage and onward referral; care coordination for people with complex problems; treatment of episodic illness; and provision of palliative care. Saltman and others (2006) have argued that this intermediate territory (between selfcare and specialist/hospital care) is changing, with primary care playing an increasing part in coordination and integration of care that is provided by different services. These new roles, together with elements of specialist care that can now be delivered in primary care settings, can be thought of as extended primary care. They are the focus of recent developments in many European countries, often seeking to bridge the divide between generalist first contact care, specialist services, and disability or home care. Developments in information technology are also challenging the concept of primary care. For example, electronic health media including the internet, telehealth and telecare are leading to significant reappraisal of where a person s first contact with health advice and support takes place, and how health providers can utilise such media and technology to support people s care. Questions for the Euro-Summit What are the three most important changes that are needed in primary care organisations to ensure they are fit for the future? How do innovations in primary care such as those in relation to technology influence our understanding of primary care that is fit for the future?

4 The diversity of primary care in Europe There are substantial differences across Europe in the number of primary care doctors per 1,000 population and the ratio of generalist to specialist doctors (see Figures 1 and 2). Figure 1: 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. www.oecd-ilibrary.org/sites/health_glance-2011- en/03/02/index.html;jsessionid=ade90c5dh8s.delta?contenttype=&itemid=/content/chapter/health_glance-2011-21- en&containeritemid=/content/serial/19991312&accessitemids=/content/book/health_glance-2011-en&mimetype=text/html

5 Figure 2: 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. ww.oecd-ilibrary.org/sites/health_glance-2011- en/03/02/index.html;jsessionid=ade90c5dh8s.delta?contenttype=&itemid=/content/chapter/health_glance-2011-21-en&containeritemid=/content/serial/19991312&accessitemids=/content/book/health_glance-2011- en&mimetype=text/html

6 There are also wide variations in public expenditure on health as a percentage of GDP (see Figure 3) and the mechanisms through which health services are funded (see Table 1). Figure 3: 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.

7 Table 1: System classification based on the organisation of the supply of basic primary coverage Source: European Commission (2010). Eurostat, OECD and WHO health data and adapted from Paris V and others (2010) Health systems institutional characteristics: a survey of 29 OECD countries. Health working paper No. 50, OECD 2010. The scale and scope of primary care organisations also varies between countries, with standalone clinics run by single-handed doctors being typical in some countries, and large health centres run by multi-professional teams including social care being the norm in others (see Table 3). Drawing on a wide body of research, Saltman and others (2006) describe national variations in the tasks fulfilled by general practitioners; the extent to which they act as the first point of contact for different types of health problems; the comprehensiveness of the services they offer; and the extent to which they provide continuity of care. The relationship between primary care doctors and specialists is another area of variation. Saltman and others (2006) note that in countries where general practitioners act as gatekeepers, they are more likely to be the first point of access to health services (for example Denmark, Ireland, Netherlands, the UK and, to a lesser extent, Norway, Portugal and Spain) and they tend to offer a more comprehensive range of services. They argue that this position favours primary care adopting a role in coordinating different services. The extent to which GPs are involved in gatekeeping in different European countries is presented in Table 2.

8 Table 2: Gatekeeping from primary to specialist care Source: European Commission (2010). Adapted from Paris V and others (2010) Health systems institutional characteristics: a survey of 29 OECD countries. Health working paper No. 50, OECD 2010 + Country Fiches. Further analysis of European primary care services by Meads (2009) provides a useful categorisation of the characteristics of primary care in different European countries. Meads links the national political context in which services develop with the organisational philosophy which underpins primary care, its organisational form, and the inter-professional relationships that exist between primary care and other services. Meads (2009) distinguishes seven organisational models of primary care (see Table 3), and argues that political and other contextual factors are the main determinants of primary care organisation. For example, in his view, the long-term influence of local civic culture (for example the collaborative funding and provision of health and disability care services in Scandinavia) will take precedence over short-term factors such as management reorganisation. He also suggests that political crises may be needed to precipitate major changes in the settings and funding of care.

9 Table 3: Categories of primary care organisation (Meads, 2009) Organisational type Structure and process Value base Service focus Location (examples) Extended general practice Managed care enterprise Reformed polyclinic Medical cabinet District health system Community development agency Franchised outreach Simple, partnership Complex, stakeholder Coalition, divisional Self-employed, independent Hierarchic, administrative Association, network Calculative Target groups Physicians group Commercial Medical Multispecialist conditions clinic Professional Maintenance Municipal premises Executive Public health General Quasiinstitutional, virtual Normative Registered patient list Health centre Affiliative improvement Local populations hospital Health stations Remunerative Payers Private, hospital premises Endpoint Patient User Client Attendees Populations Citizen Customer Countries (examples) Finland, Portugal, Greece Ireland, Italy, England Macedonian and Czech Republics Hungary N/A N/A 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. This categorisation of organisational models for primary care is not exhaustive, and nor was it intended to be by the author. However, it does provide a useful reminder that general principles for the development of sustainable fit for the future primary health care will be interpreted and implemented in the light of prevailing political and economic standards in different countries. Questions for the Euro-Summit Are there common features of successful new models of primary health care that can be codified and replicated? To what extent can and should primary care doctors act as gatekeepers to specialists? Drivers for change Health systems across Europe are grappling with the impact of health and societal challenges, and (for many) a very difficult economic context. Whilst health expenditure has shown annual growth for several years in many European countries, the impact of the global economic recession is increasingly being felt in most countries. Analysis of the impact of the global financial crisis across Europe by Mladovsky and others (2012) reveals a wide range of health policy responses, with substantial cuts in 2009/10 health budgets in some countries (notably Ireland and Greece) and continued increases in others including Germany, Sweden, Italy and France. Meanwhile, the prevalence of chronic disease continues to rise due to an ageing population, and the need for better coordinated care for people living with complex co-morbidities becomes more pressing. Poor communication between primary care, hospitals and medical specialists can result in fragmentation of care, low-quality patient experience and sub-optimal

10 outcomes (Vrijhoef and Wagner, 2009). The role of primary care in providing improved coordination of care is a subject of significant debate in many countries, for primary care is typically quite weak in this area within health systems, and struggles to influence care beyond its immediate remit. Other factors that are creating a need for new forms of primary care provision include: the development of technologies that enable new forms of information, access and involvement for patients; innovative drug treatments and therapies that enable more community and home-based care; and changes in patients expectations about access to care and the range of services that should be available to them. Developments in the primary care workforce are also creating new opportunities for people to obtain advice and treatment. For example, extended nursing roles in chronic disease management, minor injury and illness often underpin the delivery of walk-in clinics, minor illness services, and primary care for remote, rural communities. Pharmacists are increasingly providing advice on self-management of self-limiting conditions, and some offer support on chronic disease management. Furthermore, health care assistants with basic health training but no professional qualification are, in some instances, taking on roles that were formally undertaken by nurses. Many of these drivers for change can be seen within the case study summaries prepared by the organisations who will be sharing their experiences at the Euro-Summit. Questions for the Euro-Summit What solutions are emerging in primary care systems across Europe in response to these drivers for change? How might primary care organisations assume a greater role in the coordination of care for people living with complex co-morbidities? Issues to be addressed At the Euro-Summit, we will take as our starting point the current experience of trying to improve the organisation and delivery of primary care services across different European countries. We will use the experience and expertise of participants at the Euro-Summit as the basis for a careful examination of the essential characteristics of primary care systems that are fit for the future. Once we have determined these essential characteristics, we will focus on how different countries are working to improve and extend their primary care system so that it can meet future health and economic needs. We will focus on how countries are working to accelerate reform of the delivery of primary care services, and will seek to identify innovative practice, and explore what it has to offer European health policy and management practice. A series of case studies from European countries will feature in the World Café session of the Euro-Summit. This interactive session will bring to life the issues raised in this delegate briefing, allowing delegates to question senior staff from each country about the opportunities and barriers that have shaped their progress to date. Summaries of a range of these case studies will be available prior to the Euro-Summit, providing you with

11 background information. You can then learn more about the case studies during the World Café session. Questions for the Euro-Summit What are the essential characteristics of a primary care system that is fit for the future? Which emerging business models for primary care organisations are best supporting the development of services that are fit for the future? What is enabling the acceleration of primary care reform in European countries? Can we codify and replicate the factors that accelerate primary care reform? What does this offer to European health policy and management practice?

References Atun R (2004) What are the Advantages and Disadvantages of Restructuring a Health Care System to be More Focused on Primary Care Services? Copenhagen, WHO Regional Office for Europe. Health Evidence Network report. www.euro.who.int/document/e82997.pdf Accessed 7 January 2013. European Commission (2010) Joint Report on Health Systems Occasional Papers 74. http://ec.europa.eu/economy_finance/publications/occasi onal_paper/2010/op74_en.htm Accessed 7 January 2013. Meads G (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. Mladovsky P, Srivastava D, Cylus J, Karanikolos M, Evetovits T, Thomson S and McKee M (2012) Health policy in the financial crisis, EuroHealth: Quarterly of the European Observatory on Health Systems and Policy 18(1), 13 6. OECD (2011) Health at a Glance 2011. Health workforce. Medical doctors. www.oecd- ilibrary.org/sites/health_glance-2011- en/03/02/index.html;jsessionid=ade90c5dh8s.delta?conten ttype=&itemid=/content/chapter/health_glance-2011-21- en&containeritemid=/content/serial/19991312&accessite mids=/content/book/health_glance-2011- en&mimetype=text/html Accessed 7 January 2013. Paris V, Devaux M and Wei L (2010) Health systems institutional characteristics: a survey of 29 OECD countries. Health working paper No. 50, OECD 2010. Ricketts T, Naiditch M and Bourgueil (2012) Advancing primary care in France and the United States: Parallel opportunities and barriers, Journal of Primary Care and Community Health 3(3), 221 5. Saltman R, Rico A and Boerma W (eds) (2006) Primary Care in the Driver s Seat? Open University Press. Starfield B, Shi L and Macinko J (2005) Contribution of primary care to health systems and health, The Milbank Quarterly 83(3), 457 502. Tarimo E and Webster G (1994) Primary Health Care Concepts and Challenges in a Changing World. World Health Organization. Vrijhoef HJM and Wagner EH (2009) Fragmentation of chronic care: A call for clarity, International Journal of Integrated Care 9(Suppl), e172. World Health Organization (1978) Declaration of Alma Ata. Available at: www.who.int/publications/almaata_declaration_en.pdf Accessed 7 January 2013.

For more information about Nuffield Trust, including details of our latest research and analysis, please visit www.nuffieldtrust.org.uk Subscribe to our newsletter: www.nuffieldtrust.org.uk/newsletter Follow us on Twitter: Twitter.com/NuffieldTrust Nuffield Trust is an authoritative and independent source of evidence-based research and policy analysis for improving health care in the UK 59 New Cavendish Street London W1G 7LP Telephone: 020 7631 8450 Facsimile: 020 7631 8451 Email: info@nuffieldtrust.org.uk www.nuffieldtrust.org.uk Published by the Nuffield Trust. Nuffield Trust 2013. Not to be reproduced without permission.