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Primary care in Europe: Can we

make it fit for the future?

Supported by:

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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

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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, email, 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.

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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.

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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.

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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.

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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 2010 + Country Fiches.

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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

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Categories of primary care organisation

Organisational

type

Structure and

process

Value base Service focus Location

(examples)

Endpoint Countries

(examples)

Extended general

practice

Simple, partnership Normative Registered patient

list

Health centre Patient Finland, Portugal,

Greece

Managed care

enterprise

Complex,

stakeholder

Calculative Target groups Physicians’

group

User Ireland, Italy,

England

Reformed polyclinic Coalition, divisional Commercial Medical conditions Multi-specialist

clinic

Client Macedonian and

Czech Republics

Medical cabinet Self-employed,

independent

Professional Maintenance Municipal

premises

Attendees Hungary

District health system Hierarchic,

administrative

Executive Public health

improvement

General hospital Populations N/A

Community

development agency

Association, network Affiliative Local populations Health stations Citizen N/A

Franchised outreach Quasi-institutional,

virtual

Remunerative Payers Private, hospital

premises

Customer 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.

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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.

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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.

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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.

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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.

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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.

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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

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Design principles for primary care provision

• Securing the Future of General Practice1 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.

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Re-designing primary care: design principles

Access and continuity

Patients and populations

Information and outcomes

Management and accountability

Tailored encounters Early access to expertise Accessible

diagnostics

Continuity and

coordination

Multidisciplinary

working Goal-oriented care

Anticipatory care and

population health Generalism and

specialism

Quality and outcomes Use community assets Single electronic record

Contract for value Organisation and

management

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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.

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Value-based payment continuum (UnitedHealth Group)

Source: UnitedHealth Group

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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.

© Nuffield Trust 12 December 2013

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