EFPC, Goteborg

4 September 2012

Primary Health Care in the center - as part of integrated care against the background of NCD burden and ageing population

Workshopat the European Forum of Primary Care

Biannual ConferenceThe Future of Primary Health Care in Europe

Tuesday 4 September 2012, Goteborg

EFPC, Goteborg

4 September 2012

Health 2020: Strengthen people-centred health systems and public health capacity

Flexible, multi-skilled and team-oriented workforce

Improve access to affordable medicines

Foster continuous quality improvement

Primary health care as a hub for people-centred health systems with ensured continuity

Sustainable financing ensuring financial protection

Governance arrangements promoting participation and transparency

EFPC, Goteborg

4 September 2012

World Health Day 2012

EU Year of Active Ageing and Solidarity between Generations

EFPC, Goteborg

4 September 2012

WHO Strategy and action plan for healthy ageing in Europe, 2012-2020 Four strategic areas for action

Healthy ageing over

the life course

Supportive environment

s

People centered

health systems for

ageing populations

Address gaps in

evidence and

research

EFPC, Goteborg

4 September 2012

2011: The Year of Noncommunicabe Diseases

EFPC, Goteborg

4 September 2012

Discussion questions

• State of the art of PHC in WHO European region

• PHC – integrated care services

• Best practices ?• Future directions

Challenges facing the primary care professional in a changing Europe

Anna Stavdal MD/GPVice President WONCA Europe

Representing:– 22 member countries, >80 000 members– GPs working in a diversity of health care systems

Main areas of acivity: ResearchEducationQuality and patients safety

www.woncaeurope.org

Some key characteristics of our time and place:

• Migration, patients and doctors • Sosioecomic gaps are widening, within and

between countries• Great differencies between European

countries in development of PHC• New Public Management

Core messages:

• Values• Disease mongering/overdiagnosing• Patients`rights vs quality in health care

Values

Primary Care Oriented Countries Have:

Better health outcomes

Lower costs

Greater equity in health

• Fewer low birth weight infants• Lower infant mortality, especially postneonatal• Fewer years of life lost due to suicide• Fewer years of life lost due to “all except external” causes• Higher life expectancy at all ages except at age 80

Starfield 07/07IC 3762 n

Sources: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield & Shi, Health Policy 2002; 60:201-18.

«In hospitals diseases stay and patients come and go.In general practice patients stay and diseases come and go»

Iona Heath‘The mystery of general practice’.

London: Nuffield Provincial Hospitals Trust, 1995

We need GPs capable of:

• take on the risk on behalf of their patients when necassary

• willing take the responsibility of prioritizing those with the greatest need within their population

• take pole position in the primary health care team

Disease mongering/Overdiagnosing

ILL HEALTHY

HEALTH -

HEALTH +

Selfassessed health

Doctor`s assessment

The sick ones

The healthy ones

MUPS

Individuals at risk

«Anna`s doctrine»

Defend the broad range of normality of human biology and psyhology!!

patients`rights vs quality

New regulations for GPs in Norway:

«80 % of incoming phonecalls to be answered within 2 minutes»

«right to a consultation within 5 days, independent of cause»

Real need or just consumers` demand?

The main task for the Primary Health Care professional is to balance political ambition, patients rights and demands, and professional quality in the daily work

Thank you for your attention!

University of the West of Scotland

• Scotland’s largest modern university with 20,000 students

• Largest School of Health, Nursing and Midwifery in Scotland

• Local university to 40% of Scotland’s population across four campuses

• Representing EU funded, WHO supported Family Health Nursing project (FamNrsE)

BackgroundThe World Health Organization (WHO) (2008) suggested that in the last three decades in general the population of the world is healthier and is living longer.

The global health challenges are significant. WHO (2009) outlined that the current leading global risks and causes of death around the world include;  

• High Blood Pressure: contributing to 13% of deaths (7.1 million people). 

• Tobacco use: contributing to 9% of deaths (4.9 million people).  

• High blood glucose contributing to 6% of deaths. The number of people with diabetes is expected to double by 2030.

• Physical inactivity contributing to 6% of deaths.

• Overweight and obesity contributing to 5% of deaths.  

• Workforce challenges, demographics and the economy impact on the workforce too.

What Should Concern Us: Common AmbitionKey overarching aim of HEALTH21:

“promoting and protecting people’s health throughout the course of their lives; and reducing the incidence of and suffering from the main diseases and injuries” (WHO, 1998, p. 8).

Developing a Road Map for Health Service Delivery (WHO Europe, Copenhagen, 2012)

• Ageing population and workforce, with chronic diseases and multiple morbidity, requires structural integration (based on defining needs of population groups in integrated ways).

• A bigger change in terms of increasing efficiency and re-shaping public and provider expectations is needed, and case studies (e.g. chronic condition management, emergency response etc) evaluating consistency and efficiency of interventions should be used to develop recipes for success (common denominator solutions).

• The new approach to generalism appears to be the real challenge, and requires a transforming scenario leading to a new pattern of services

provided and accessed by educated patients, populations and providers.

Reinforced by EU FamNrsE ProjectThere are both similarities and differences in the way health services are delivered within countries. This is due to a range of factors including population, organisational structure of health service and availability of resources and healthcare workforce.

Each country has changing demographic profiles.

Each country has similar public health issues including an ageing population and increasing long-term conditions such as Cardiovascular disease, Respiratory disease, Diabetes and Cancer.

Principles and Challenges• Progress cannot be made through professional or system isolation

and will involve collaboration with individuals, families, communities, hospitals, Primary Health Care (PHC) teams, the public and private sector.

• PHC is part of the life-health journey – a continuum.

• Future demands from compressed periods of complex co-morbidity.

• Primary care is health and social care as a function but person centred

and team delivered.

• “Specialist generalist” – needs recognised and rewarded.

• Who is the gatekeeper – individual, clinical practitioner, health system?

Continuum of Care – a Model

Person centred

care

Supported self care

Anticipatory care

Community crisis

intervention

Rapid access to diagnosis

and treatment

Intensive community

rehabilitation

Long-term care and end

of life care

Promotion of Health and WellbeingMartin and Duffy (2012)

Do not quote without authors’ permission.

Promotion of Health and Wellbeing

New Service Model

Proactive Tasks

Responsive Tasks

Core ObservationsWe need to harness and share academic and professional experience across European countries.

We need to strive for a consistency of approach with high quality standards, while recognising, encouraging and valuing local/national variation.

Governments Across Europe are encouraged to:• Put in place comprehensive public health policies responsive to

the needs of the population at a community, regional, national and international level.

• Make clear policy statements and resource commitments that advance integrated approaches to the development and delivery of accessible health systems.

• Ensure that the health system is affordable to the local, regional and national economy and at the point of access for the individual.

• Promote  health and wellbeing with a focus on the prevention of illness.

Governments across Europe are encouraged to:• Stimulate service models that are flexible, person centred and designed to support people who present with complex co-morbidities.

• Encourage community engagement and social enterprise approaches to service development and delivery that foster entrepreneurship and community sustainability.

• Develop a health workforce based on the principles of team work and interdisciplinarity.

• Recognise the core contribution of the “specialist generalist” role in the primary care setting.

Thank you –Discussion

Family Health Nursing inEuropean Countries

Berlin Conference 25th and 26th October 2012http://www.uws.ac.uk/familyhealthnursing/

www.ihf-fih.org

Hospitals and the challenges of Multi chronic conditions

E de Roodenbeke, PhDCeo of International Hospital Federation

www.ihf-fih.org

INTERNATIONAL HOSPITAL FEDERATION

The international organization is representing national hospital and health care organizations from all over the world

• Sharing universal values for improved performance of health care services and better access to care for the population

• World leader in facilitating the exchange of strategic knowledge and experience in the hospitals and health care delivering sector.

• The voice of the hospitals and healthcare delivery industry and their decision makers in major international health organizations

• Providing many opportunities for networking: Congress, Publications, Projects, Web, Training, …

www.ihf-fih.org3939

Hospitals and Multi chronic conditions

• Hospitals: What are we talking about ?

• Challenges for hospitals to respond to chronic conditions and PHC approach

• Way forward to better face future

www.ihf-fih.org40

Hospitals: What are we talking about ?

40

What is in common between a small rural hospital in a remote location and a large university hospital in a dense urban center?

Are they similar?

www.ihf-fih.org4141

Hospitals: What are we talking about ?• Role and function vary between types of hospitals

• Role and functions vary within countries according to location (remote /urban) and ownership (public/private)

• Role and functions vary a lot between countries according to history, governance model, ownership

No international definition or classification of hospitals but a generic model can be elaborate:

- recognize its nature as a production organization - interface it with policy options- identify its key inputs and outputs

www.ihf-fih.org42

42

Care

Prevention Diagnosis

Reconstruction Rehabilitation

Supervision

Support

Safety

Training

Research

Information System

Human Resources

Management and leadership

Drugs Consumables

Health Technologies

Regulation

Financing

Planning

Policy & governance

Market forces Population needs & demands

Coordination

Services

www.ihf-fih.org43

Education & disease awareness

Wellness

Investigation & Monitoring

Patient at Risk

Intervention & treatment plan

Critical episode

Prevention & follow up

Recurrence

Remote monitoring & care management

Advanced diseaseH

Role of Hospitals for Chronic Conditions

www.ihf-fih.org

Predictive care

Mapping risks & advising43

?

www.ihf-fih.org44

Challenges for Hospitals with healthcare

• Continuity of care : make it happen!!

www.ihf-fih.org45

Challenges for Hospitals with healthcareCoordination : Who is in charge, how is it organized and financed?

GP’s and

www.ihf-fih.org4646

Challenges for Hospitals with healthcare

• From a specialty centered organization to a patient’s centered organization– Education of doctors : hyper specialization– Complexity and knowledge management : silo approach– Quality of care & productivity : importance of volume

Today’s hospitals are not well organized to deal with multi-chronic conditions :o Transforming hospitals of all nature to better care and coordinate careo Breaking down the large hospital model by an “industrial revolution”

www.ihf-fih.org4747

Challenges for Hospitals with healthcare

• How to serve population in rural/remote places– Care givers are reluctant to work alone– Care givers are reluctant to leave in remote places Initiatives to boost rural hospitals as hub for PHC Promises from e-health in relation with health-hubs

• How to deal with inadequate utilization of hospitals:– Emergency as an alternative to unavailable first line care– Hospitals as a solution for social situations– Important shortage of capacity in long term institutions Invest in pre and post hospital alternatives to reduce pressure

on hospitals

www.ihf-fih.org48

Challenges for Hospitals with healthcare• Inadequate payment system in most countries :

– Activity based and only in relation to sole provider– No recognition and payment of coordination Full redesign of payment systems with multiple payments to

better support different functions

• Payers and coverage do not favor innovation:– Silo approach with competition between payers– Coverage not supporting patient empowerment Re-engineer the coverage mechanisms in relation with

political decentralization

www.ihf-fih.org49

Way forward to better face future

A need to bring clarity in the discussion on PHC

• Principles for health systems

• A package of low cost and high impact activities

• Organizations delivering health services to the population

www.ihf-fih.org50

Way forward to better face futurePHC as a principle for health systems

Adoption by all stakeholders of the PHC principles with commitment to implement them in their activities :- Patient centered services - Patient empowerment- Quality and patient safety- Equity of access to health services- Accountability and transparency- Organizing continuity of care

www.ihf-fih.org51

Way forward to better face futurePromote low cost and high impact activities

• Support implementation of evidence based low cost & high impact activities

• Support research by initiating a project similar to the DCPP (http://www.dcp2.org/main/Home.html)

• Customized essential first level comprehensive care• Support patient empowerment

• Reconsider role of hospitals in delivering low cost/High impact services.

www.ihf-fih.org52

Way forward to better face futureOrganize efficient service delivery

• Country specific distribution of role and functions performed by different providers according to their location

• Better recognize the different functions performed by all health care organizations

Care

Prevention Diagnosis

Reconstruction Rehabilitation

Supervision

Support

Safety

Training

Research

Information System

Human Resources

Management and leadership

Drugs Consumables

Health Technologies

Regulation

Financing

Planning

Policy & governance

Market forces Population needs & demands

Coordination

Services

Source: hospitals in a changing Europe McKee &Healy, Euro Observatory, 2002,Open University Press

www.ihf-fih.org53

Way forward to better face futureResponsibilities for policy makers

• Stop hospital blame game: does not help progresses• Have a clear policy with priorities and principles applicable to

hospitals• Implement right incentives aligned with PHC principles

– Payment systems and coverage mechanisms– Decentralization of stewardship – No one fits all approach in the country– Accountability and M&E frameworks (especially on inappropriate activity)– Reward good practices

• Mobilize investments funds to support transformation of hospitals• Support research and dissemination of new effective technologies

www.ihf-fih.org54

Way forward to better face futureResponsibilities for providers…including hospitals!

• Efforts on clinical pathways for multi-chronic conditions

• Holistic approach of patients : patient condition versus specific diseases

• Matrix approach of healthcare (specialties & conditions)

• Stronger accountability and transparency on results

www.ihf-fih.org55