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© Nuffield Trust 12 December 2013 Primary care in Europe: Can we make it fit for the future? Supported by:
© Nuffield Trust 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
© Nuffield Trust 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, , 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.
© Nuffield Trust 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 Health workforce. Medical Doctors.
© Nuffield Trust 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 Health workforce. Medical Doctors.
© Nuffield Trust 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.
© Nuffield Trust Gatekeeping from primary to specialist care 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 Country Fiches.
© Nuffield Trust Multiple factors influencing primary care supply and demand Lack of access to social care Ageing populations Rising patient expectations Rising prevalence of chronic disease and multi-morbidity New providers/supply induced demand Primary care New technologies and treatments
© Nuffield Trust Categories of primary care organisation Organisational type Structure and process Value baseService focus Location (examples) Endpoint Countries (examples) Extended general practice Simple, partnershipNormative Registered patient list Health centrePatient Finland, Portugal, Greece Managed care enterprise Complex, stakeholder CalculativeTarget groups Physicians’ group User Ireland, Italy, England Reformed polyclinicCoalition, divisionalCommercialMedical conditions Multi-specialist clinic Client Macedonian and Czech Republics Medical cabinet Self-employed, independent ProfessionalMaintenance Municipal premises AttendeesHungary District health system Hierarchic, administrative Executive Public health improvement General hospitalPopulationsN/A Community development agency Association, networkAffiliativeLocal populationsHealth stationsCitizenN/A Franchised outreachQuasi-institutional, virtual RemunerativePayersPrivate, hospital premises CustomerPoland 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.
© Nuffield Trust 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.
© Nuffield Trust 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.
© Nuffield Trust 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.
© Nuffield Trust 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.
© Nuffield Trust 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.
© Nuffield Trust Primary care that is fit for the future needs to be: Comprehensive Person-centred Population-oriented Coordinated Accessible Safe and high quality And sustainable in terms of: Finance Workforce Public trust Fit with wider health system
© Nuffield Trust Design principles for primary care provision Securing the Future of General Practice 1 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.
© Nuffield Trust Re-designing primary care: design principles Access and continuity Patients and populations Information and outcomes Management and accountability Tailored encountersEarly access to expertise Accessible diagnostics Continuity and coordination Multidisciplinary working Goal-oriented care Anticipatory care and population health Generalism and specialism Quality and outcomesUse community assetsSingle electronic record Contract for value Organisation and management
© Nuffield Trust 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.
© Nuffield Trust Value-based payment continuum (UnitedHealth Group) Source: UnitedHealth Group
© Nuffield Trust 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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