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Trends and Drivers of Change in European Primary Care

Dr Rebecca Rosen Senior Fellow The Nuffield Trust 29th Jan 2013

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Primary care as first point of access to health services

• First-line clinical care for undifferentiated health problems

• Increasing focus on prevention and screening

• May be founded on general practice, but is more than the work of generalist doctors, and may include other disciplines

• Provided by generalist clinicians, sometimes working as part of a multi-professional team (doctors, nurses, pharmacists or other community health workers)

• Is typically a level of care between self care and specialist care

• May be designed around a registered population

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Changing scope of primary care

• Traditionally including: • assessment of undifferentiated symptoms; • diagnosis, triage and onward referral; • treatment of episodic illness • provision of palliative care • prevention and health promotion .

• Increasingly likely to involve: • care coordination for people with complex problems; • areas of ‘specialist’ care (eg endoscopy, minor surgery.

diagnostics ) enabled by new medical technologies • new forms of access such e consultations

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Multiple drivers of demand

Lack of access to social care

New medical

technologies

Aging populations

Rising patient expectations

Rising prevalence of

chronic disease

New providers/ supply induced

demand

Primary care

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Wide variations in inputs across Europe

Relative provision of GPs, specialists and other doctors in Europe No. of doctors per 1000 population in Europe

Public expenditure on health as a % of GDP in EU member states (2008)

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Primary care ‘fit for the future’

Attributes • Comprehensive • Patient-centred • Co-ordinated • Continuous if required • Accessible • Safe and High Quality • Population focused •Adapted from Agency for Healthcare Research and Quality 2013

Sustainability • Financial • Workforce • Public trust • Fit with wider health system

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The Primary Care Paradox....

‘... a paradoxical situation: the tension between the relative weakness and un-attractiveness of this level of care versus the intention to assign critical strategic functions to it’ From:Primary Care In The Driver’s Seat? Saltman, Rico and Boerma (eds) 2006

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Drivers of change: political and policy trends

• Significant regional variations across Europe • Political and economic foundations of health systems

• Impact of financial crisis on health sector

• Interactions between health and other sectors (eg social care)

• Some overarching themes • Coordination of care

• Diversification of providers/growing role for private sector and increasing use of choice and competition

• Experiments with primary care purchasing and new payment mechanisms

• Care delivery innovations

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Mechanisms for change: Integration and coordination

• Croatia: GP led polyclinics. • GPs employed under contract (health insurance funds) renting

space to specialists with whom they can make shared care decisions about complex patients

• Germany: Disease management programmes (DMPs) • Lead doctors (usually a family physician) coordinate care

related to selected chronic conditions. • Evidence based criteria for referral to specialists • Patient self-management support • Financial incentives to providers to deliver DMPs

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Mechanisms for change: Privatisation, markets and new business models

• Large scale privatisation of family medicine clinics in CEE

• Pluralisation of provision and new primary care providers

• Corporatisation of primary care

• New ‘convenience clinics’ and walk-in centres

• New business models for blending primary and specialist services (polyclinics, integrated care pathways)

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Mechanisms for change: payment innovation

• Dutch DBC payments for chronic conditions • Integrated payments for selected chronic conditions • Payment for a year of care delivered to specified standards • Negotiated with groups of practices

• Clinical commissioning in the English NHS • Compulsory GP membership of budget holding clinical

commissioning croups • Influencing primary care practice and buying other services

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Mechanisms for change: delivery innovations

Electronic and telephone access to primary care • NHS Direct :

• 24 hour telephone advice from nurses following algorithms • NHS Direct web site

- symptom checker - patient information pages - healthy living advice

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Challenges for the Eurosummit

• 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 primary care reform in European countries

• Can we replicate and embed these factors

• What does this offer to European health policy and management practice?

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