Conclusion and observations In general, the following conclusions can be drawn:

• A major observation from the study of health care systems in Europe is their variability. Health care systems are differently funded and structured, and services are provided in diverse settings. The differences in the role of primary care are a prominent aspect of this variation.

• Strong primary care appeared to be conducive to reaching health care system goals. The structure of primary care, and access to, coordination and comprehensiveness of primary care are all critical aspects of primary care that reduce unnecessary hospitalizations for conditions that can also be treated in primary care. Population health is better in countries with relatively stronger primary care compared to countries with relatively weaker primary care.

Table 4.2

Correlationofprimarycarestructureandprocessvariableswithoutcomevariables

OUTCOME PROCESSofPC

STRUCTURE ofPC

Accessibility Continuity Coordination Comprehensiveness

Totalhealthexpenditure,year2009(US$purchasingpower

parities(PPP),percapita)^a -0.01 -0.01 0.08 0.11 0.22

%changetotalhealthexpenditure,years2000–2009

(US$PPP,percapita)^a 0.04 0.02 0.12 -0.10 -0.37

%pop.ratingqualityoffamilydoctorsas“good”,year2007^b -0.05 -0.06 -0.04 -0.14 0.04 Asthmaadmissionrateper100000pop.,years2007–2009^c -0.23 -0.13 0.05 -0.24 -0.36 COPDadmissionrateper100000pop.,years2007–2009^c -0.15 -0.11 0.13 -0.28 -0.09 Diabetesadmissionrateper100000pop.,years2007–2009^c -0.01 -0.40 -0.11 -0.10 0.25 DiabetesPYLLper100000pop.aged,years2005–2009^d 0.07 0.16 0.12 -0.09 -0.02 IschaemicheartdiseasePYLLper100000pop.,

years2005–2009^d -0.27 -0.00 0.07 -0.25 -0.52

CerebrovasculardiseasePYLLper100.000pop.,

years2005–2009^d -0.21 0.20 0.17 -0.15 -0.42

Bronchitis,asthmaandemphysemaPYLLper100000pop.,

years2005–2009^d -0.23 0.08 0.05 -0.43 0.02

ConcentrationIndex(very)badself-ratedhealth,year2006^e -0.27 -0.26 -0.43 0.05 -0.02 ConcentrationIndexasthmaprevalence,year2006^e 0.11 0.32 0.04 0.01 0.06 ConcentrationIndexdiabetesprevalence,year2006^e 0.05 0.02 0.11 0.12 -0.01

Notes: ThematrixprovidestheresultsofthePearsoncorrelationanalysisofstudyvariables.TheboldPearsoncorrelationindices arestatisticallysignificant(p≤.05).COPD–chronicobstructivepulmonarydisease;PYLL–potentialyearsoflifelost.

a Theanalysesincludeddataforall31participatingEuropeancountries.

b Theanalysisincludeddatafor27countries,excludingIceland,Norway,SwitzerlandandTurkey(lackofdata).

c TheanalysisforasthmaandCOPDincludeddatafor23countries(excl.Bulgaria,Cyprus,Estonia,Greece,Lithuania, Luxembourg,RomaniaandTurkey(lackofdata);alsoexcludedfordiabetesFrance,Hungary,Slovakia.

d Theanalysisfordiabetes,ischaemicheartdiseaseandcerebrovasculardiseaseincludeddatafor24countries;excl.Bulgaria, Cyprus,Latvia,Lithuania,Malta,RomaniaandTurkey;forbronchitisdatafrom23countries,alsoexcl.Switzerland.

e Theanalysisincludeddatafor27countries,excl.Iceland,Norway,SwitzerlandandTurkey.

Source: Kringosetal.,2013c.

• Furthermore, it was found that countries with relatively strong primary care have lower socioeconomic inequalities in self-assessed health.

• Primary care strength, however, was not associated with patient ratings of the quality of primary care. Contrary to other studies, it was found that countries with a stronger primary care structure have higher total health care expenditures. However, countries with more comprehensive primary care have a slower growth in health care expenditures.

With regard to the structure of primary care, we can conclude that:

• Concerning health care governance, it appeared that important functions were decentralized and that regulation on continuing medical education was a point of attention. Guidelines for GPs were often developed without their involvement.

• Concerning economic conditions, an east–west divide was visible in expenditures and income of providers. In most countries GPs were self-employed.

• An issue of workforce development was the ageing of providers. Workforce plans or forecasting of human resources was unknown in most countries.

Nurses in primary care were much less organized than physicians.

For the process-related issues of primary care, it appeared that:

• The process of care was relatively well developed in Denmark, Spain and the United Kingdom, but the process dimensions were much more heterogeneous than the structure dimensions.

• A concern on accessibility was the widespread geographical inequalities.

In many countries patients need to pay out of pocket for primary care (especially for prescribed medicines). The likelihood that GPs visit patients at home strongly varies between countries. Outside office hours, access to primary care was usually inferior to access during office hours.

• In many countries, informational continuity was not well developed.

• Countries strongly differed in conditions for coordination, such as patients being registered with a GP of their choice. As solo practice dominates primary care, GP practices were small-scale enterprises in many countries.

• The range of services provided by GPs showed different profiles. In countries with gatekeeping GPs, these were particularly strong as the doctor of first contact. Solo GPs provide more follow-up care than GPs working in larger settings.

Our attempt to explain the variation led to the following observations:

• In western Europe relatively weaker primary care systems are more frequent:

◊ in traditional SHI (or Bismarckian) systems, like Belgium, France and Germany;

◊ where primary care is provided in smaller-scale – mainly solo – practices;

◊ where there is emphasis on freedom of choice (both for patients and doctors);

◊ where demand for care is channelled via co-payments.

The following features in the national context are associated with strength of primary care:

• Former communist countries show the strongest improvement in primary care strength.

• Countries with social democrat politics are more likely to have stronger primary care systems.

• Wealthier countries are more likely to have weaker primary care systems.

• Social values in a country were related to the strength of primary care; for instance values in favour of family care (children taking care of ill parents) were related to weaker primary care systems.

References

Armingeon K et al. (2010). Comparative political data set III 1990–2008. Berne, Institute of Political Science, University of Berne.

Boerma WGW, Van der Zee J, Fleming DM (1997). Service profiles of general practitioners in Europe. British Journal of General Practice, 47:481–486.

European Observatory on Health Systems and Policies (accessed in 2011).

Health System Profiles (HITs) publications.

Groenewegen PP, Delnoij DMJ (2003). De Nederlandse gezondheidszorg in Europees perspectief [The Dutch health care system in European perspective].

In: Aakster CW, Groothof JW (Eds), Medische sociologie [Medical Sociology].

Groningen/Houten, Wolters-Noordhof:155–172.

Kringos DS et  al. (2013a). The strength of primary care in Europe:

an international comparative study. British Journal of General Practice, 63(616):e742–e750(9).

Kringos DS et al. (2013b). Political, cultural and economic foundations of primary care in Europe. Social Science & Medicine, 99:9–17.

Kringos DS et al. (2013c). Europe’s strong primary care systems are linked to better population health, but also to higher health spending. Health Affairs, 32(4):686–694.

Pelone F et al. (2013). How to achieve an optimal organization of primary care services delivery at system level: lessons from Europe. International Journal for Quality in Health Care, 25(4):381–393.

Sciortino P (2002). A service profile of Maltese general practitioners. A provider survey of the general practice component of the Maltese health care system.

Master’s thesis, University of Malta, Guardamangia.

Sidel VW, Sidel R (1977). Primary health care in relation to socio-political structure. Social Science & Medicine, 11:415–419.

TNS Opinion & Social (2010). Special Eurobarometer 340 Science and technology. Brussels, European Commission.

TNS Opinion & Social & TNS (2007). Special Eurobarometer 283 Health and long-term care in the European Union. Brussels, European Commission.

WHO Regional Office for Europe (2011). European Health for All Database (HFA-DB) [offline database]. Copenhagen, WHO Regional Office for Europe.

World Values Survey Association (2009). World Values Survey 1981–2008 official aggregate v.20090901. Madrid, ASEP/JDS.

Chapter 5

Overview and future challenges