The Organisation of Primary Care in Europe

1、the organisation of primary care in europeposition paper 2009lead author:professor geoffrey meads,institute of health sciences research,medical school, university of warwick, ukeditorial group members:professor jan de maeseneer (chair), university of ghent, belgiumdr gabriela parvulescu, craiova uni

2、versity, bucharest, romaniaprofessor paolo tedeschi, bocconi institute, milan, italyprofessor laszlo kalabay, semmelweis university, budapest, hungaryprofessor tatyana pasenyuk, odessa state medical university, ukrainedr sara shaw, university college, london, ukthe european forum for primary carethe

3、 organisation of primary care in europepart 1purposethe aim of this monograph is to examine a representative range of modern organisational developments across europe and to define the contemporary position of primary care in relation to these.the need now for such a position statement arises from t

4、he accelerated and sometimes radical nature of recent organisational changes across european primary care settings. the scale and pace of these has increased significantly during the period that followed the assumption of public health responsibilities in article 152 of the 1999 amsterdam treaty, an

5、d the resultant first eu and who regional health strategies (1,2). making sense of such changes is important if they are to be understood not just in terms of their economic determinants, but also as organisational developments with the potential to either reinforce or undermine a particular philoso

6、phy of service. the values inherent in this philosophy have meant that primary care has signified in the past much more than simply a literal first point of health services contact, albeit one that is outside of hospital. rather it has meant a generalist and personalised approach which is both compr

7、ehensive and longitudinal and which appreciates presenting individual illness as something more than just formal disease. as a result its effective practice has required negotiated interventions which are based on a sensitive awareness of a patients context and relationship patterns as much as they

8、are on data derived from scientifically labelled conditions and specialist clinical procedures. a fundamental organisational issue today in europe is whether or not the contemporary innovations to organisational structures and processes will permit such practice to continue. how this issue is addres

9、sed may help decide whether or not, at the continental level, new policy initiatives are considered either necessary or even desirable to combat alternative emergent service philosophies for primary care.the bottom line in considering this issue is that of reciprocity between the different countries

10、 and cultures of eastern, central and western europe. the past two decades have witnessed these sub-regional areas struggling to move on organisationally from their standard models of the semashko multi specialist clinics, public institutions and the social market. as yet there is no common agreemen

11、t on the way forward for the organisation of primary care. there could scarcely, therefore, be a more timely contribution from the european forum for primary care (efpc) in seeking to promote transferable learning across the whole of its 52 countries region.accordingly, the role of this position pap

12、er is twofold. first, like its predecessors it should facilitate the positive exchange and application of knowledge and experience between the full range of primary care practitioners in different countries, with the local case summaries from ten countries of part 2 being of particular interest in t

13、his respect. and secondly, through its analysis at part 1 and concluding recommendations in part 3, it looks to provide the means by which the european forum may both define its own policy position, and then offer the specific arguments and influential data which may enable such partner institutions

14、 as the eu commission, who european office, wonca and parallel european professional associations to shape theirs.approachalthough this monograph is not designed as a peer reviewed research paper its data capture methods do, however, broadly align with those of a formal study. accordingly, it draws

15、first on the literature and documentary search which led to the creation of a database resource for international transferable learning, at the university of warwick (uk). this consists of more than 320 relevant reports and articles, covering the period from 1997 to 2006, on global primary care deve

16、lopments (3). for the purposes of the present paper this has been augmented by a review of subsequent publications and the more recent individual country profiles from the european observatory on health (4). of these by far the most significant is the december 2006 volume entitled primary care in th

17、e drivers seat (5). this wide ranging and authoritative book reviews contemporary organisational reforms in primary care. its thematic analysis includes a central three chapter section which addresses directly the three principal organisational developments arising from different countries new insti

18、tutional arrangements. these are the emergence of new public-private provider combinations; the growth in primary care based commissioning agencies; and innovations in cross-boundary collaboration for more integrated service delivery (6,7,8). the observatory text was produced by 31 national and inte

19、rnational experts and this paper seeks to both endorse and build on its analysis.a number of the chapters in primary care in the drivers seat contain interesting illustrative case studies (e.g. 9,10). the second source of data for the present essay is similarly sets of interviews and observation vis

20、its to local country sites deliberately selected for the explicit purpose of preparing case studies. these are intended to accurately indicate the scope and direction of modern organisational developments in european primary care. these case study accounts, in abbreviated form, are set out below. th

21、ere are ten in number, which is in line with the number originally chosen this year by the world health organisation in its commemorative publications for the thirtieth anniversary of the seminal alma ata declaration (11). significantly none of the first ten sites chosen by the who are in europe. th

22、is omission may be felt to reflect the failure or reluctance of this continent to genuinely embrace for itself the principles of primary health care - equity, participation and cross-sectoral partnerships - as articulated in the 1978 declaration (12). each of the selected european sites in this pape

23、r was nominated as an exemplar of a countrys modern organisational practice in primary care by the national policy and professional leaders that were interviewed in the research done either for this paper or for its preceding articles (e.g. 13). in chronological order of investigation the countries

24、covered through case studies here are: finland, portugal, greece, the czech republic, macedonia, ireland, poland, italy, hungary and england. by design the studies are evenly spread across eastern, central and western european sites. the intention is to reflect the notions of reciprocity and shared

25、learning that are important even at the stage of methodological development. this is especially pertinent in 2008 when the challenge for western european states is to extend their majority middle class service models of primary care to marginal and minority population groups, while for many eastern

26、europe countries it is precisely the other way around. the evidence from the ten formal case study sites selected for this paper has been supplemented by informal visits to primary care locations in a number of other countries since 2002, including scotland, the netherlands, belgium, wales, slovenia

27、, france, turkey, switzerland, croatia and spain, and earlier excursions elsewhere in the baltic, scandinavian, russian and the black sea states. the third and final main substantive point of reference for this paper is theoretical. the approach is weighted in favour of contextual forces as being th

28、e decisive variable in the organisational development of primary care. this bias stems from earlier international research which, for example, has emphasised how critical sense of place is in converting health policies into primary care practice (14), and how the long term enabling influences of loc

29、al civic cultures prevail over shorter term pre-disposing and precipitating factors, such as management restructuring exercises, media stories and political crises, as the most important prerequisites for major organisational change in community settings (15). the principal conceptual framework util

30、ised in this paper comes, however, from the warwick university based international primary care research programme already cited and its principal publication (16). the programme identified a global typology of six primary care organisations, distinguished from each other conceptually by their separ

31、ate forms of governance, their different ethical underpinnings and service orientations, and their distinctive physical premises and vocabularies. for example, the extended general practice typically has a simple structure of professional partners for its governance with services geared to its regis

32、tered patients and a classic normative value base of public obligation. by contrast, the reformed polyclinic, is usually structured around medical specialists with a private business orientation that connects its commercial value base to its clients. similarly the competitive modern managed care ent

33、erprise now has a structure which accommodates many investors calculating the dividends to be derived from particular performance targets, while the district health system is a bureaucratic collaboration in pursuit of overall population benefit. figure 1 below provides a comprehensive summary profil

34、e of the alternative models. the six organisational types are: the extended general practice, the managed care enterprise, the reformed polyclinic, the outreach franchise, the community development agency and the district health system. figure 1 provides a summary of their main characteristics, whic

35、h are explained in turn in more detail at the beginning of the case studies set out in part 2 of this paper. the summary includes an additional seventh organisational model which is prevalent in and particular to european settings: the medical office. in practice, of course, there is often an overla

36、p between the different organisational types within individual countries. in europe, nevertheless, the interaction between the different models between 2002 and 2009 - our designated time frame - is largely confined to the first five in the list. by contrast the organisational mode of the whos ten c

37、hosen case studies in 2008 is overwhelmingly that of the community development agency or the district health system, which prevail in latin america and sub saharan africa.figure 1 categories of primary care organisationorganisational typestructure and processvalue baseservice focuslocation (examples

38、)endpointextended general practicesimple, partnershipnormativeregistered patient listhealth centrepatientmanaged care enterprisecomplex, stakeholdercalculativetarget groupsphysicians groupuserreformed polyclinic:coalition, divisionalcommercialmedical conditionsmulti-specialist clinicclientmedical of

39、ficeself-employed, independentprofessionalmaintenancemunicipal premisesattendeesdistrict health systemhierarchic, administrativeexecutivepublic health improvementgeneral hospitalpopulationscommunity development agencyassociation, networkaffiliativelocal populationshealth stationscitizenfranchised ou

40、treachquasi-institutional, virtualremunerativepayersprivate, hospital premisescustomertwo final sources of intelligence for this work must also be credited. the first is the contribution of the european forum for primary care workshop hosted in the hungarian capital of budapest by semmelweis univers

41、ity on the 23 july 2008. this was attended by 13 nominated experts from nine countries with a further five states represented in the list of corresponding members. appendix 1 gives their names with details of the workshop programme. at this meeting a first draft of this paper was considered. the sec

42、ond source is the contribution of a parallel piece of research exploring current policies and priorities for primary care research across europe, including specifically for organisational developments. this research is directed by dr sara shaw at university college, london (uk). the two projects top

43、ic guides (see appendix 2) and anonymised interview notes have been shared, and one joint case study, in poland, undertaken. the very limited extent to which research evidence and findings are used by primary care policy makers in general has been striking, and is in itself a justification of the ef

44、pc mission to seek to better integrate the practice of primary care with its policies and research. issuesover the past two decades decentralisation and provider de-regulation have been principal political pressures for change in the organisation of primary care across europe. in the wake of these f

45、orces have followed an increased flexibility and variety in both the forms of local resource management and the status of hybrid service delivery agencies. the examples of each are numerous. those organisations with newly extended decentralised executive responsibilities for primary care ranged, by

46、2006, from 431elected municipal councils in norway and 89 appointed territorial insurance funds in the russian federation to the seven parishes of the andorran principality and 17 regional communidades autonomas in neighbouring spain. similar trends are apparent in terms of the mixed status of prima

47、ry care service units. local experimentation again covers a broad spectrum, from state transfers of public dispensaries and registered patient lists to newly designated independent general practitioners with private medical offices in romania, and comparable concessionary arrangements in slovenian a

48、nd macedonian health centres, to a plethora of organisational innovations in public-private partnerships across the united kingdom, norway and sweden that include new types of foundation and charitable trusts, medical and multi-professional cooperatives and both walk-in and urgent health care call c

49、entres. as these examples illustrate considerable local energy has been released. but the increased diversity that comes with decentralisation and provider de-regulation can also mean fragmentation and a loss of overall coherence in the organisation of primary care. for many european countries there

50、 are serious concerns regarding the capacity to implement modernising organisational reforms. while this is most evident in such eastern and central european countries as croatia, moldova, serbia and the former yugoslavian republic (fyr) of macedonia, it is also seen as a major obstacle by west euro

51、pean policymakers we have interviewed in sweden, ireland, belgium and the netherlands. in all these states the missing ingredients are those of vision and strategy and the issue, paradoxically for such an inherently bottom-up mode of service, is the perceived need for european level leadership to pr

52、otect and steer the future organisation of authentic primary care. the attachment of the who to organisational models that promote public health, but not necessarily primary care, through structures and processes of public participation and vertical control that are not culturally appropriate in eur

53、opean environments, throws this need into even sharper relief.this need is directly linked to the second issue: that of counterbalancing the financial drivers and economic doctrines for organisational reform in primary care with equivalently powerful social imperatives and pastoral ideas. the pressu

54、res for cost containment in relation to hospital and drugs expenditure are now so immense that even such countries as norway, sweden and germany, where historically health expenditure has been a relatively high proportion of gdp, often no longer view primary care as a separate community service sect

55、or with its own ethos and raison detre, but as an adjunct to secondary care services. accordingly, the norwegian organisational reforms of 2002 diminished the influence of its peer based utposten (professional communication networks) by merging research councils and administrative regions and defini

56、ng primary care merely as that which is outside the new independent hospital enterprises. subsequent charging and business development policies for general practices have sought to incentivise those which substitute effectively for acute services. the focus of both norwegian central policy and resea

57、rch has shifted firmly away from primary health care to hospital based quality improvement and specialist scientific medicine, as the recent development and growing output of the national knowledge centre for health services demonstrates. similarly in sweden, where county councils assumed responsibi

58、lity for national expenditure on prescribed drugs in 1998, to go with their existing management of primary care services, over a third of the 1100 health centres nationwide are now privately run. with an expensive three tier structure of district county and central county hospitals and six specialist medical regions for just nine million people, swedish local councillors are looking to share the financial burdens and retain their elected positions by showing they can control the l