Organization of integrated health services

Family-oriented care

As mentioned in Chapter 5, families (households) are the basic unit of society where health care providers will be able not only to address patients’ somatic physical complaints but also to take into account the psychological and social aspects of their condition. It is important for PHC providers to know the circumstances in which patients live: their housing, family circumstances, work, and social or physical environment may all have a considerable bearing on their illness. Unless care providers are aware of these circumstances, presenting symptoms may be misinterpreted and conditions may go unrecognized and untreated. The result may be unnecessary diagnostic and treatment procedures, thus increasing costs without helping to address the real problems.

Serving a specified population improves the relationship between health professionals and the population. One feature that contributes strongly to providing the full range of services described so far is that each family health physician and family health nurse should serve a specified population, defined either as a geographical catchment area or through enrolment on a list. In both cases, it is also important for people to be able to choose freely a professional whom they can identify as

“their own” from among the list of professionals practising in the area. The establishment of such a link between health professionals and the population makes it very much easier to carry out PHC functions and activities. It also ensures effectiveness, since physicians can more easily and quickly recognize the health problems of the particular patients they know throughout their life course.

Furthermore, continuity of care is ensured as one person is followed by the same health professional for a continuous period.

Self-care

As mentioned in section 4.4, much more health can be created if health care systems recognize and acknowledge the actual and potential contribution people can make to their own health (self-care)

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and take active steps to empower them to do so. It is a public responsibility to ensure that citizens receive extensive, accurate and timely information on health and health care through various communication channels; information itself exerts a key influence on people’ s health and on how they use health care services.

Health professionals should also act as agents, guides and counsellors for their patients in their relationships with other agencies and with social and other health-related services. Both at national and at local community levels, the creation of patients’ organizations should be encouraged and their actions supported.

PORTUGUESE PHARMACIES PROVIDE COUNSELLING SERVICES TO THE COMMUNITY

One of the counselling services is a needle exchange programme, “Say no to a used needle” , to help prevent sexual and blood transmission of HIV among drug users. The project has been running since October 1993 through the 2500 pharmacies spread across the country, and it has been a success as measured by the number of used syringes and acceptance of the project by drug users. Another counselling service is helping to prevent primary and secondary diabetes, by promoting early diagnosis and by advising people about healthy lifestyles – advice that is taken up by a number of “ patients” . The European Forum of Pharmaceutical Associations and the WHO Regional Office for Europe (EuroPharm Forum) promotes similar projects in a number of countries.

Source: Matias, L. & Teles, A. Portuguese National Pharmaceutical Association (unpublished data). Soares, M.A. et al.

Lisbon, Santa Maria Hospital (unpublished data).

In many countries, there is a growing vogue for the use of “alternative” treatments and service providers. The perception of human beings as holistic entities with the right to make free choices recognizes and tolerates, even welcomes, the existence of alternative health care alongside conventional medicine. However, in this area, too, high ethical standards need to be met, consumers must be protected against exploitation, and public funds should be used only for treatments with scientifically proved effect.

Home care

The need for home care is increasing in line with the changing demographic structure, improvements in technology and the demands of the population. The home is the setting where health care is most commonly provided. Regular home visits by health personnel play an important role in health promotion and disease prevention services. Follow-up of chronically ill or convalescing patients generally takes place in the home environment.

PHC services should take on a special role in this respect towards their population, acting together with them as co-producers of health and health care: informing and advising people on how to preserve their health and supporting them, with care provided at home, when they care for themselves.

Primary care must also support physically disabled people or those with mental health problems, making major efforts to provide the care that will keep them functioning in their home environment and, if possible, in the labour market. However, sheltered accommodation must be provided for those who need it – only in severe cases should resort be made to nursing-home care. Health programmes for these client groups must be established jointly by the health services, social services, schools, NGOs and, in particular, self-help groups.

Lastly, PHC must also support the elderly, in view of their growing numbers and increasing social isolation and hardship, especially among those suffering from chronic disease and disability. It should provide and coordinate care for this group of patients, including home care and – when required – institutional care in nursing homes. These need to be designed to cater for the varying needs of different patients: facilities for day care, night care and short- and long-term care should be part of, or at least work closely with, PHC teams.

Schools and workplaces

As mentioned in Chapter 5, schools and workplaces require more attention as important settings for the provision of PHC. School health services have important promotive, preventive, diagnostic and therapeutic roles to play concerning children’ s health and educational attainment.

Occupational health services are concerned with all aspects of the relationship between occupation and health. Workplaces require special attention in terms of preventive services and work safety.

While they usually require a separate organizational structure, they are none the less part of PHC and should work in close liaison with other primary care settings.

Referral systems

An effective referral system requires a well organized referral and feedback mechanism between primary, secondary and tertiary care. Not all the conditions that patients present can be dealt with by PHC. Patients who have complicated or life-threatening conditions must be referred as required to the appropriate specialist in good time, in order to avoid unnecessary complications and unwarranted disability. The ability to recognize those situations that require referral is one of the important skills that all health professionals working in PHC should develop. A necessary corollary of referral is the two-way exchange of information between primary, secondary and tertiary levels, in order to ensure follow-up and continuity of care, since PHC services will have the responsibility of monitoring and assisting patients after the care given at the secondary and tertiary levels. Many Member States have gone further, making it mandatory that the patient’ s first consultation with the health services should be in a PHC setting, which is thus formally identified as the “ gatekeeper” . Indeed, such a system contributes to efficiency, since unnecessary or overly intrusive consultations with secondary and tertiary care services are avoided.

Establishing a gatekeeping system certainly requires well trained physicians working in well organized PHC settings. It should be noted that patients may be referred not only to secondary

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and tertiary medical services but also to other health professionals working at the primary level, or to agencies outside the health sector such as social welfare services.