1. From Policy to Practice and back to Policy Prof. Dr. J. De Maeseneer, MD, PhD Department of Family Medicine and PHC- Ghent University, Belgium General Practitioner (part-time), Community Health Centre, Ledeberg-Ghent (Belgium) Chairman European Forum for Primary Care Chairman Expert Panel on Effective Ways of Investing in Health-EC Director International Centre for PHC and FM – Ghent University, Belgium WHO-Collaborating Centre on PHC Paris, 9.04.2014

2. No conflict of interest

3. 1.Expert Panel on Innovative Ways of Investing in Health 2.The model of PHC-Centres in Belgium 3.Policy:strategies for change From Policy to Practice and back to Policy

4. Expert Panel on effective ways of investing in Health ( EXPH) * To provide independent non-binding advice on matters related to health care modernisation, responsiveness, and sustainability * Set up by Commission Decision of 5 July 2012 http://ec.europa.eu/health/healthcare/docs/dec_panel2012_en.pdf * 12 members, nominated for 3 years, by Decision 21 May 2013 http://ec.europa.eu/health/healthcare/docs/dec_members_expert_panel_ 2013_en.pdfhttp://ec.europa.eu/health/healthcare/docs/dec_members_expert_panel_ 2013_en.pdf * Started its activities on 11 July 2013

5. The public consultation has been launched (deadline: 11 May 2014). http://ec.europa.eu/health/expert_panel/consultations/primarycare_en.htm http://ec.europa.eu/health/expert_panel/consultations/primarycare_en.htm

6. Opinion on Definition primary care – Definition History Alma-Ata / Vuori / Tarimo / Starfield / IOM Core-definition 'The Expert Panel considers that primary care is the provision of universally accessible, person-centered, comprehensive health and community services provided by a team of professionals accountable for addressing a large majority of personal health needs. These services are delivered in a sustained partnership with patients and informal caregivers, in the context of family and community, and play a central role in the overall coordination and continuity of people’s care.'

7. Opinion on Definition primary care – Main points 3. Referral systems (including gatekeeping) - Emphasises the importance of using primary care as the preferred entry point into the health system - To be effective, referral systems (gatekeeping) must involve: - a strong and responsive high-quality primary care system - a patient-centered approach - timely access to medical imaging results (by primary care providers) - a prompt response by secondary care - maximal subsidiarity to avoid long waiting terms - electronic referral processes as much as possible - interactions between referral and payment systems

8. Opinion on Definition primary care – Main points 4. Financing primary care The opinion recommends - to ensure an adequate level of financing for primary care, - to promote equitable access to primary care (when user charges -> protecting mechanisms needed for people with low incomes or regular users) - to provide incentives for efficiency and quality in primary care delivery, including care coordination (trend towards blended provider payment systems can be effective when financial incentives are integrated)

9. 1.Expert Panel on Innovative Ways of Investing in Health 2.The model of PHC-Centres in Belgium 3.Policy:strategies for change From Policy to Practice and back to Policy

10. The changing society a.Demographical and epidemiological developments b.Scientific and technological developments c.Cultural developments d.Socio-economical developments e.Globalisation and “glocalisation” ‘By 2030, 70% of the world population will live in an urban context’ (Castells, 2002) By 2100, 85%?

14. Socio-economic inequalities in health Healthy life expectancy in Belgium (Bossuyt, et al. Public Health 2004)

15. http://www.who.int/social_determinants/resources/csdh_media/primary_health_care_2007_en.pdf

16. Primary Care delivery in Belgium: type II Primary Health Care Centres Type of Services: Patient-list: territorial; “referral” Reactive care: broad-spectrum: physical, mental, social,… Diagnostic (Imaging, lab): outsourced, GP- controlled Comprehensive home care (incl. palliative) Prevention and screening: call-recall; contract for health promotion towards the local community Community Oriented Primary Care (COPC) Training of GPs 16

17. Primary Care delivery in Belgium: type II Primary Health Care Centres Types of payment: Integrated mixed needs-based capitation (since 01.05.2013) negotiated PHC-Insurance companies Allowances (informatics, GMR, Impulseo, care trajectories diabetes and CRF,…) No co-payment for patients Incentives for prevention (regions, municipalities) 17

18. Integrated mixed needs-based capitation: the “needs-variables”  Demographic variables  Social-economic variables  Morbidity variables  Contextual variables

19.  Age/sex (41 combinations)  Widow  Low income: < 15 000,00EUR  Self-employed workers  Deceased in that year  Disability  Urbanization index in the neighbourhood  Medical supply index in the neighbourhood  Handicap  Help from public welfare centres  Impaired functional status  Cardiac diseases  COPC  Asthma  Cystic Fibrosis  Diabetes combined with chronic cardiac condition  IDD  NIDD  Exocrine pancreatic diseases  Psoriasis  Rheumatoid arthritis, Crohn’s disease, ulcero-hemorragic recto-colitis  Psychosis: young adults  Psychosis: elderly people  Parkinson’s disease  Epilepsy  HIV  Chronic hepatitis B & C  Multiple sclerosis  Post-transplant immunosuppression  Alzheimer  Thyroid diseases  Thrombosis  Coagulation disorders  Protected habitat

20. Implementation  Based on an (electronic) “photograph” of the population on the list of the different PHCC’s → photograph made annually  Each PHCC receives a specific “capitation” for the patients on the list

21. The integrated needs-based mixed capitation system:  stimulates prevention, health promotion and self-reliance of the people,  as there is a global payment for all disciplines, there is an incentive to task- shifting and subsidiarity,  Prevents risk selection  Stimulates a global approach to a broad range of problems, avoiding the fragmentation and disease-orientation

22. Study: comparison payment systems

23. 2008: Federal Knowledge Center for Health Care Fee-for-service ↔ Capitation Strengths capitation system  high degree of accessibility, especially for vulnerable groups  no risk selection  patients in the capitated system use: less resources in the secondary care less medications  the quality of care was at least as good or better

24. Primary Health Care Centre: -Family Physicians; nurses; dieticians; health promotors; social workers; … -5800 patients; 60 nationalities -Integrated needs based mixed capitation; no co-payment -COPC-strategy

25. 1978 family practice in poor neighbourhood 1980 first nurse and foundation of the community health centre 1986 interprofessional team 1995 capitation financed system Community Health Care Centre Botermarkt: history

26. ACCESSIBLE Geographical context Notwithstanding ethnicity, culture, income, administrative status,… No risk selection <> high prevalence of multiproblem patients Patients on the list The 19th century “belt” around Ghent

27. Wgc Kapellenberg WGC Watersportbaa n 01.04.2010 WGC Rabot

28. INTERPROFESSIONAL TEAM Family physicians Nurses Social work Health Promotion Dietician Administratieve staff and receptionist Ancillary staff Podologist External health care workers : physiotherapists, psychologists

29. INTERPROFESSIONAL ELECTRONIC PATIENT RECORD Family physicians Nurses Social work Dieticians International Classification of Primary Care (ICPC-2); Future: + International Classification of Function (ICF)

30. Family Physicians During the day –consultations –appointments –home visits At night (from 19.00 until 08.00) –Cooperation with local GP-service During the weekend (Friday 19.00 pm to Mo 08.00 a.m.) –Three “on call” GP-posts in Ghent

31. Nursing Appointments at the health centre –Daily direct access –Referral by GPs or receptionists Home visits –Daily –Referral by GPs or receptionists –Only when indicated by the medical and functional condition

32. Nursing Prevention Follow – up blood pressure Family-planning management Participatory patient management –Diabetic consultation: 3-monthly –COPD, asthma: Spirometry

33. Diabetes clinic Diabetes clinic Objectives: –Improving the care for diabetes type 2 patients through a structured multidisciplinary follow-up and health education –To help patients to cope with their condition (“empowerment”) –Improve self-efficacy of patients –To tackle social inequalities in relation to chronic diseases

34. Diabetes clinic Diabetes clinic Programme: –biomedical and behavioural follow-up by nurse and family physician, following guidelines –exchange of experiences by the patients –contact with dietician (2 x / year) –“diabetes-cooking” (3 x / year)

36. Social Work social workers Social work in the health centre includes : –first intake, exploring the problem –information and counseling –advocating, mediating –supporting, psychosocial guidance –referral to specialised services –administrative support, application for allowances, budgetplanning –establishing patient centered networks of care

37. Social Work Problems situated on different domains of life Multiproblem cases Not (yet) reached by other social services Undocumented residents On appointment or crisis intervention No waiting lists

38. Dietician Gives information about healthy food and counsels : –Patients with general dietary problems –Patients with gastro-intestinal problems –Patients with cardiovascular problems –Patients with diabetes –Patients with kidney-problems –Children with obesity Only on appointment

39. Reception and administration First contact of patients Organisation of the surgery Dispatching of incoming phone- calls Information to the patients General administration Handling of the capitation-system

40. Health promotion Health as a resource for social, economic and personal development / important aspect of quality of life Achieving equity in health and reducing socioeconomic differences in health.

41. Health promotion Mission statement Health Centre Botermarkt “Prevention of illness and health promotion as very important aspects in the daily routine of a primary health care centre” 2 levels: –Patient – centred –Community - centred

42. Interdisciplinary work - Internal meetings Weekly disciplinary teams Interdisciplinary meeting for care-providers with case-discussions worker-oriented discussions community and policy oriented themes Monthly planning-meeting with the whole team Executive committee

43. External meetings Platform of providers and services –3-monthly meetings, trainings, lunchdebates,… –Meeting, detecting problems, signalize problems to stakeholders, working on projects,… Committee of Flemish Health Centres Local medical quality circle City Committee on health problems of asylum seekers and ‘people without papers’ Local Social Policy Advisory board (city of Ghent)...

44. COMMUNITY ORIENTED

46. COPC-example: dental problems: periodontal disease in childhood Risk factor for: Diabetes Coronary Heart Disease Preterm birth and low birth weight Osteoporosis

47. Identifying health problem: Family physicians/nurses: problematic oral condition of todlers, leading to feeding problems, crying, not sleeping,... COPC-project : from individual care to community health care

48. Results research children 30 months old: 18,5 % early symptoms of childhood caries (7,4 % – 29,6 %) 100% need for treatment! Correlation with deprivation nationality (Eastern-Europe) no previous dentist consultations COPC-project : DENTAL FITNESS

49. Childhood caries: Information and Sensibilisation Involving providers, social workers, parents, schools… Strategies: Community oriented, intersectoral, participation. Educational platform for students in dentistry COPC-project : DENTAL FITNESS

50. Accessible primary dental care Centre for Primary Oral Health Care Botermarkt Ledeberg (CEMOB) Started 01/09/2006 Towards accessible oral health care ! Ghent University COPC-project : DENTAL FITNESS

51. Integration of personal and community health care The Lancet 2008;372:871-2

52. Education and training Training for : – undergraduatie medical students – family physician trainees – nursing students – social work students –...

53. The future: WHO-six star provider -assess and improve the quality of care -make optimal use of new technologies -promote healthy lifestyles -reconcile individual and community health requirements -work efficiently in teams THE SIX STAR PROVIDER - leadership attributes and acts as change agent

54. The Lancet 2010;376:1923-58

57. Universities should invest in strong departments of family medicine and PHC Integration of family medicine in the undergraduate curriculum

61. 1.Expert Panel on Innovative Ways of Investing in Health 2.The model of PHC-Centres in Belgium 3.Policy:strategies for change From Policy to Practice and back to Policy

62. Created in 2005 EFPC Multi-Country Study-Visits

63. Barcelona 2014 September 1/2

64. Website: www.euprimarycare.org www.euprimarycare.org Tel: +31 30 272 96 11 E-mail: info@euprimarycare.org info@euprimarycare.org

65. Improving health and primary health care around the world through Primary Health Care Centres Learn more at: www.ifchc2013.org

66. Debate:  SCORE the PHC-practice in your country/region in comparison with the PHC- centres model in Belgium: use a comparative score (--;-;0;+;++) looking at: °RELEVANCE (CARE THAT REALLY MATTERS…) °EQUITY (INCL. ACCESSABILITY) °QUALITY °COST-EFFECTIVENESS °PERSON- AND PEOPLE- CENTREDNESS °SUSTAINABILITY

67. Debate:  What would be the most important policy- measure to improve the quality of PHC in your country/region?  What is/are the most important obstacle(s) to make change happen?  What could be appropriate advocacy- strategies?

69. Management versus leadership Management versus Leadership Planning and budgettingEstablishing direction Organizing and staffingAligning people Controlling and problem solving Motivating and inspiring Source: J.P. Kotter. A force for change: How leadership differs from management (1990)

72. Thank you… jan.demaeseneer@ugent.be WHO Collaborating Centre on PHC

73. Ghent University Jan.DeMaeseneer@ugent.be