Good practices and challenges for structuring primary care

In addition to data relevant to the indicators, information was gathered on current priorities and challenges related to structural aspects of primary care.

Main points from these reports will be discussed here. The full country reports are in Volume 2.

National strategies and plans

In many countries some explicit and public strategy or more detailed plan is available to guide the development of primary care and against which progress can be assessed. Indeed, the endorsement and effectiveness of such documents are influenced by the political will of administrations and they may be reviewed, changed or completely reformulated as political or economic conditions change.

DK ES NL PT SIUK

EE IT LT

NO RO HIGH EE NO DK LT PT IT ES NL RO

SIUK

FI BE DE FR

SE TR AT BG CZ GR LV MEDIUM

BG CZ GR AT FR LV SE TR BE DE FI

CH IEMT HU CY ISLU

PL SK LOW

CY IE ISLU

MT PL CH HU SK PC workforce

development HIGH MEDIUM LOW LOW MEDIUM HIGH PC economic

conditions

LOW BG CY CZ

GR ISLU PL AT LV SK

MEDIUM

EE NO FR HU LT SE TR

DE BE IT RO

HIGH

IEMT CH DK PT ES FINL SIUK governancePC

PC workforce development

However, guiding documents on primary care can be an important basis and reference for health service provision to the population. National strategies can be the basis for a comprehensive primary-care based health system. In Spain, for instance, this has been the case during a process of regionalization of its governance and in France a start has been made on developing team-based primary care.

Still there are countries where an explicit plan for the development of primary care, including more comprehensive service provision and better care coordination, is absent. Strong primary care does not develop spontaneously but requires a deliberate explicit policy specifying the division of roles between levels of care, the curative and preventive services provided at the primary care level, the coordination function in the health care system and incentives for providers. Current evidence has shown that health care systems based on a well-developed primary care system perform better in terms of population health and cost-containment. In the absence of explicit policies and regulation on primary care such advantages may be missed.

Inter-professional collaboration

Maintaining the responsiveness of health care systems is a continuing challenge for decision-makers and health professionals. For instance, the ageing of the European population and the increased prevalence of noncommunicable diseases require new ways to cope with changing health needs. Chronic conditions and multi-morbidity can be treated more effectively by different closely collaborating health care workers among whom tasks may be reshuffled. In prevention and anticipatory medicine an integrated primary care level has a major role to play, preferably in relation to community and occupational services. It will be a challenge to realize this, especially in the many countries where the heart of primary care consists of GPs working in solo practice.

Furthermore, professional education should prepare workers for new skills, new skill-mixes and teamwork. Continuing education should also be tuned to changing demands for care and the development of new tasks. Finally, it will be the role of regulation and funding of primary care to create the right incentives to make this work.

Countries that have a better professional infrastructure or a stronger academic tradition in primary care are more often ahead of others in this development. If a vision on the future role of primary care has been developed and formulated countries can learn from each other how to go in this direction.

Education and training

In recent years significant progress has been made in preparing physicians for working in primary care. Mandatory periods of postgraduate training, varying from three to five years, both in universities and in primary care practice, have upgraded the primary care workforce in various countries, although there is much still to be improved. The extent of the training and subjects studied vary considerably, and in a number of countries the domain of general practice is still limited (for instance because GPs are not trained to provide care for children).

In some countries postgraduate training for GPs is very limited.

Regarding the professional development of other primary care professions, such as home care nurses and community nurses, the situation is less positive.

For these professions the opportunities for obtaining advanced education are limited, mainly to countries in western Europe with well-developed systems of primary care. An integrated and comprehensive primary care service requires investment in people as well as in systems.

Strategies to promote performance

Approaches to encourage better performance in primary care vary across the countries and are related both to the culture and the structure of the health care system. As, in most countries, GPs have a key role in reforms to achieve more efficiency and create more responsive services, performance-related incentives are mostly directed to general practice. Countries may use the force of law without much measurement of actual performance, or they may try incentives, such as pay-for-performance, to make health care workers develop prioritized services and, at the same time, monitor innovative approaches.

2.6 Conclusion

This chapter has depicted aspects of primary care across European countries, in terms of the structure and organization of the primary level of care, including its supporting structures of policy-making, financing, education and workforce.

• Governance for primary care was relatively well developed and differences between countries were modest, but relatively little policy was devoted to multidisciplinary collaboration.

• Concerning the economic conditions, it appeared that expenditures for primary care vary strongly (as far as these could be identified at all).

Furthermore, GPs usually earn (much) less than medical specialists.

For the rest, differences on economic conditions were small.

• On workforce development differences were larger. Important here were differences between countries in the position of nurses and medical specialists in primary care.

• Taking all dimensions on primary care structure together, a relatively consistent pattern appears: countries ranking high on one dimension are likely to be high on others as well.

References

Frederickson HG (2005). Whatever happened to public administration?

Governance, governance everywhere. The Oxford Handbook of Public Management.

New York, Oxford University Press.

Keohane R (2002). International organizations and garbage can theory. Journal of Public Administration Research and Theory, 12:155–159.

Chapter 3