How to strengthen Primary Health Care and municipal capacity towards health gains? Example from the Netherlands Dr. Gerard Molleman Bureau Maat Manager Health Promotion & Epidemiology Municipal Health Service Nijmegen Project leader Academic Centre Public Health AMPHI
Content Challenges in Dutch Health Policies Structure Primary Health Care and Public Health How to get a healthy city Collaboration Primary Health Care and Public Health Examples: obesity, elderly people
Challenges in Dutch Health Policies Rising costs of cure and care More elderly with more demands for help Serious lack of qualified staff in the near future Higher expectations in general from health care Health inequalities Especially on determinants of health like obesity, smoking, physical activity and mental health
Health Inequalities in the Netherlands,Nijmegen Differences between High and Low SES Life expectancy Healthy years 7 years 12 years Determinant L SES H SES Smoking 33% 17% Alcohol (above norm) 14% 14% Overweight 60% 32% Mental problems (MHI 5) 16% 10% Monitor Nijmegen Region; adults 19-65 years, (survey 2009)
Challenges in Dutch Health Policies Rising costs of cure and care More elderly with more demands for help Higher expectations in general from health care Serious lack of qualified staff in the near future Health inequalities Especially on determinants of health like obesity, smoking, physical activity and mental health Necessity for new answers Settings approach and more emphasis on prevention New ICT-possibilities Shared responsibilities of public health and health sector
Structure Dutch health system Primary Health care Public health & health promotion
Primary Health Care General practitioners Physicians for elderly Home care (nurses) Physical therapists Dieticians Psychologists Funding : Central role for Insurance companies Normal medical expenses: Health Care law (health insurance) Exceptional costs: Exceptional Medical Expenses Act (AWBZ) Only individual prevention programs
Trends in Primary Health Care Central Issues: Fragmentation through specialisation of care and cure tasks No one is responsible for patient/client in general No one is responsible for the whole system Medicalization and less patient empowerment Prevention at collective and individual level strictly divided Possible solutions: Individual disease management programs Organisation of health care at community level One nurse + one physician per patient From hospital to community, from care to prevention, from system to person Collaboration with public health
Legal Basis Public Health National health monitor Inspectorate report Public Health Law National health policy paper Local health promotion practice Local health policy paper Local health monitor ZonMW 4de preventieprogramma - verwachtingen VWS Den Haag, 8 oktober 2009 9
Trends in Public Health Policy responsibility Health Promotion primarily on the local level: integrated approach through settings (school, community, workplace, etc) nationwide: focus on obesity, diabetes, smoking, alcohol, mental health locally: focus on health inequalities, obesity, alcohol stimulation of local government to pay more attention to national priorities Funding: Public Health, Health Promotion & prevention Local government: execution and implementation of collective prevention programs National government: knowledge infrastructure, pilots
Opportunities for prevention Primary health care: direct contact with patients Frequent contacts with patients with chronic diseases Elderly People with low SES Possible influence on lifestyle Smoking Obesity, physical activity and nutrition Alcohol Attention for fall-related injuries by elderly I don t quit smoking because my doctor didn t said anything about that Public Health: creating a healthy environment Rules and regulations Creating facilities Education on main life style determinants Political commitment
PH and PHC increasingly aware of: More attention for prevention Neither can solve problems alone Strict division of funding between collective and individual prevention is counterproductive Insurance companies benefit of solutions organised and paid in the public domain: they should co-invest Shared answers are necessary for health gains
Elements of model LaLonde Human Biology Physical Environment Health Health Care (organisation) Social Environment Lifestyle
Challenge: How to get a healthy city 1. Health is a responsibility for all institutions in society 2. Health is always a political issue 3. Healthy environment produces better health 4. Involve Public Health in creating a healthy physical and social environment 5. For disease management Primary Health Care have to involve Public Health / life styles 6. Insurance companies have to contribute to Public Health (percentage for prevention has to raise from 2% to 10%) 7. Empowerment of patients/ target groups 8. Smarter organization and cumulative effect of interventions
Challenge: How to get a healthy city (See also the Ottowa charter) 1. Health is a responsibility for all institutions in society 2. Health is always a political issue Political commitment 3. Healthy environment produces better health Healthy environment 4. Involve Public Health in creating a healthy physical and social environment 5. For disease management Primary Health Care have to involve Public Health / life styles 6. Insurance companies have to contribute to Public Health (percentage for prevention has to raise from 2% to 10%) Empowerment 7. Empowerment of patients/ target groups Connect Public Health and health care 8. Smarter organization and cumulative effect of interventions Connect initiatives
Primary Health Care and Public Health Different worlds, stereotypes People don t know each other (enough) Strict financial division doesn't help Different governance Professional versus political How to deal with it? Get to know each other Work on common projects Respect and understanding helps Learning by doing
Initiatives and instruments Knowledge workshops in primary health care Home care, general practitioners, Municipal Health Services, University Medical Centre, welfare sector Health analyses at neighbourhood level for priority setting for joint action in an integrated manner and as an instrument for monitoring/evaluating joint actions
Health analyses at neighbourhood level
Initiatives and instruments Knowledge workshops in primary health care Home care, general practitioners, Municipal Health Services, University Medical Centre, welfare sector Health analyses at neighbourhood level for priority setting for joint action in an integrated manner and as an instrument for monitoring/evaluating joint actions Regional Health Agenda for tackling various kinds of institutional and system barriers (institutes and local government & insurances companies) Integrated life style programs as examples Use of ICT-possibilities to find new ways in doctor-patient communication and strengthen the patient s responsibility
Example 1: Obesity The Foresight causal map of the inter-relationship between the different classes of factors driving the obesity epidemic Societal Psychology Indiv. Psych. Food Production Intake Drivers Indiv Phys. Activ. Physical Activity Envir. Physiology
Example 1: Obesity Connecting individual and collective prevention Primary Health Care Importance of stimulating patient responsibility Screening on juvenile obesity and offering special programs Adults: screening and offering Physical Activity as prescription ; In general: opportunities to stimulate patients to get Combined lifestyle interventions (CLI) (paid by the insurance companies) Public health perspective: Healthy environment stimulating physical activities, healthy food, etc. Healthy schools with programs against obesity Enough opportunities for physical exercise after Combined Lifestyle Intervention
Control own life, avoid or delay frailty Not Frailty Frailty (Temporarily) Frailty, Not complex Frailty, complex Example 2: Healthy aging Connecting individual and collective prevention Lifestyle Housing, Mobility Necessary: Focus prevention Social Welfare Cure, Care Current situation: Cure & care
Example 2: Healthy aging Connecting individual and collective prevention Primary Health Care Monitoring frailty Identifying remedies (practical, welfare, medical, mental, spiritual) Stimulating empowerment: what one can do him/herself Connecting with local support Public health perspective: What can be done collectively in stead of individually? Fall-reduction: test of home-security; fall-prevention training; support-system of the housing company Loneliness: collective diner-opportunities; skype for elderly (PAL 4)
Key messages Public health and primary health care need each other to get more and better integrated programs They both play their individual role in solving health problems: Primary health care have access to target groups that are difficult to reach for public health Public Health stimulate a healthy environment In the end these two aspects are cost effective Joint action helps to reduce health inequalities It is stimulating to work together and learn from each other: Just do it!!