Changes to primary care and ambu lat ory care

This section focuses on changes affect ing primary and ambu lat ory care, includ-ing changes to fundinclud-ing levels, prices, payment methods, deliv ery and skill mix.

Funding and prices

Five coun tries repor ted that the crisis created an impetus to increase funding or prices for primary care (Table 5.5). Five repor ted redu cing funding or prices, although in all cases efforts were made to limit the impact of cuts. In Estonia and Latvia, cuts to primary care spend ing were delib er ately kept lower than cuts to spend ing in other areas. Germany froze adjust ments to ambu lat ory phys i cian Table 5.5 Reported changes to primary care funding and prices, 2008–13

Policy responses Countries

Increasing funding or prices for

primary care Belgium, Hungary, Lithuania, Republic of

Moldova, Netherlands Decreasing funding or prices for

primary care Belgium, Estonia, Germany, Latvia,

Romania Source: Survey and case studies.

payments, then increased them by €1 billion. Romania reduced the point value base for GP payment between 2009 and 2011, but increased it in 2012.

Payment methods

Six coun tries repor ted changes to primary care phys i cian payment; in most cases this involved trying to link payment to GP perform ance (Box 5.2), although only directly in response to the crisis in Latvia. Ukraine intro duced a pilot for capit a tion- based primary care payment.

Primary care deliv ery and skill mix

Twenty- one coun tries repor ted changes to primary care deliv ery, some inten-ded to promote access to primary care and the role of primary care in the health system, and mainly in direct response to the crisis (Table 5.6). In Greece and Portugal, changes were part of EAP require ments. The EAP in Portugal required the follow ing meas ures: increas ing the number of family health units (USF); setting up a mech an ism to guar an tee a more even distri bu tion of family doctors across the country; moving some hospital outpa tient services to USF;

moving human resources from hospital to primary care settings; increas ing the number of patients per GP; and extend ing perform ance assess ment to all primary care units. As a result of the EAP in Greece, a new primary care law was passed in 2014.

Belgium: Increased by 20 per cent lump sum payments to GPs for main tain ing the Global Medical File, follow ing care traject or ies and being on call; intro duced finan cial incent ives for GPs to estab lish prac tices in deprived areas; revised finan cial incent ives to motiv ate GPs to use elec tronic health records; adjus ted refer ence amounts for hospit als to encour age day care and services provided up to 30 days before the start of hospital stay.

France: Introduced perform ance- related pay for GPs on a volun tary basis in 2009; expan ded in 2012.

Latvia: From 2013, GPs failing to meet new quality criteria saw their annual remu ner a tion (capit a tion payment) reduced by up to 9 per cent.

Romania: Reduced the per capita part of GP payment in favour of fee- for- service.

Serbia: Introduced a capit a tion formula for primary care under which not more than 2 per cent of salary will be real loc ated based on perform ance.

Source: Survey and case studies Box 5.2 Efforts to link GP payment to perform ance, 2008–13

114 Economic Crisis, Health Systems and Health in Europe

Table 5.6 Reported changes to primary care deliv ery and skill mix, 2008–13

Policy responses Countries

Reduction in the number of primary

care facil it ies Iceland, Spain

Structural reforms to strengthen primary care, includ ing shift ing care from hospit als to primary and community care settings Increased access hours in primary care Latvia, United Kingdom (Wales)

Mandated choice of provider and freedom of estab lish ment for accred ited private providers

Sweden

Referral policy Slovakia (abol ished refer ral), Switzerland (proposed but rejec ted gate keep ing), Ukraine

Skill mix Belarus, Portugal, Slovenia

Source: Survey and case studies.

Three coun tries repor ted chan ging the health worker skill mix (that is, the combin a tion or group ing of health staff), all in the area of primary care.

Slovenia shifted GP prevent ive activ it ies to registered nurses in 2011, in order to reduce GP work load and refer rals to second ary care. The health insur ance fund employed addi tional nurses for this purpose but in 2012 funding was reduced and payment for addi tional employ ment cut by 30 per cent. Portugal’s EAP required recon sid er a tion of the role of nurses, leading to a new family nurse project to strengthen the deliv ery of care for chronic condi tions. Since 2009, Belarus has tried to improve the effi ciency of health worker roles and distri bu tion, includ ing through the intro duc tion of doctor assist ants in outpa tient primary care settings.

Policy impact and implic a tions

Public spend ing on outpa tient care contin ued to grow between 2007 and 2011, but the rate of growth was consid er ably slower than before the crisis, falling to almost zero between 2009 and 2010 (Figure 5.1). Disaggregated data (Figure 5.3) point to reduc tions in one or two years in most coun tries for which data are avail able; these coun tries did not neces sar ily report cuts to primary care funding in our survey (Table 5.5) as cuts may not have been the result of expli cit policies. Sharp reduc tions of five per cent or more occurred in Estonia, Lithuania, Poland and Slovakia, and even larger reduc tions occurred in Greece, Latvia and Romania. Although reduc tions were in many cases tempor ary, as repor ted in our survey, these figures give rise to concerns about access to primary and outpa tient care, partic u larly in Greece and Romania, where

reduc tions were exper i enced in two or more years. Maintaining access to primary and outpa tient care, espe cially mental health services, is vitally import-ant in a crisis in which house holds face increased finan cial insec ur ity.

Health systems with strong primary care are asso ci ated with improved perform ance, includ ing greater effi ciency (Kringos et al. 2010). It is there fore posit ive that coun tries made an effort not to derail ongoing efforts to strengthen primary care and that improv ing primary care formed part of EAP require ments in Greece and Portugal.

Three devel op ments are worth high light ing. First, several coun tries ensured that any new funds made avail able were linked to evid ence of better perform-ance on the part of GPs, poten tially an effect ive way of address ing a finan cial constraint. Although pay- for- perform ance programmes do not seem to lead to substan tial improve ments in quality (meas ured in terms of health outcomes), they can contrib ute to stronger governance (Cashin et al. 2014).

Second, a very small number of coun tries intro duced skill mix changes to shift primary care tasks to nurses, a strategy that may require initial invest ment but is likely to enhance quality and effi ciency in the longer term (Bourgeault et al. 2008; Kringos et al. 2010). However, the effect ive ness of skill mix reforms depends on the incent ive struc ture in place and changes need to account for quality, deleg a tion and respons ib il ity.

Third, several coun tries tried to shift care from inpa tient to outpa tient or primary care settings, another change that is likely to require upfront invest ment and a raft of accom pa ny ing policy meas ures if it is to be effect ive (for example, strength en ing of altern at ive facil it ies and services, reduc tions in inap pro pri ate admis sions and quicker discharges).

Figure 5.3 Public spend ing on outpa tient curat ive and rehab il it at ive care, annual per capita growth rates, 2007–11, selec ted European coun tries

Source: OECD- WHO- Eurostat Joint Data Collection (2014).

116 Economic Crisis, Health Systems and Health in Europe

Not surpris ingly, several coun tries encountered finan cial and polit ical obstacles in trying to imple ment these devel op ments. For example, despite EAP require ments, only one new family health unit was estab lished in Portugal in the first trimester of 2013, partly due to finan cial constraints. In Ireland, extra funds alloc ated to primary care in 2012 to deliver 300 extra staff and to roll out free GP care to people with certain illnesses were not delivered, while in Slovenia the addi tional funds needed to employ nurses to take on GP tasks were cut after the first year of imple ment a tion. Swiss efforts to intro-duce changes to promote better coordin ated care, includ ing integ rated care insur ance plans with gate keep ing and lower user charges, were rejec ted in a refer en dum in 2012.

It is clear that most efforts to strengthen primary care and make it a hub of service deliv ery require plan ning, polit ical commit ment, upfront invest ment and time, partic u larly to accom mod ate shifts in health worker tasks and patterns of use by patients. As the exper i ence of some coun tries shows, all of these factors may be chal len ging in a crisis situ ation. This should not deter poli-cy makers from focus ing on an import ant area of reform.