Primary care: strengthening the health system's first port of call
Discussion forum of the Federation of Austrian Social Security Institutions, the European Health Forum Gastein, the Medical University of Graz
“Primary care in the driver's seat” was the title for a discussion in Vienna between experts on international trends in primary care. The symposium was organised by the Main Association of Austrian Social Security Organisations (HVB), together with the European Health Forum Gastein (EHFG) and the Graz Medical University course on Public Health.
“The Austrian healthcare reform has established the concept of 'best point of service'. It follows that every service provided by the health system should be provided wherever it is optimally located – both in terms of resources and quality,” said Dr Josef Probst, HVB's Director General. “Strengthening primary care is a key element of our healthcare reform. We now need to discuss in detail what the role of primary care is, and what resources are necessary to provide it. It is helpful in this connection to analyse models which have proved successful in other countries.”
EHFG President Brand: Primary care doctors especially important in times of crisis
The European Health Forum Gastein is lending its support to this discussion with European know-how and its international network. “European comparisons show that, especially in financially difficult times such as the current economic crisis, a stable and efficient system of primary care providers is essential. Only then do citizens and patients have contact with people who can guide them safely through a rapidly changing healthcare landscape have,” said EHFG President Prof Helmut Brand (Director, Department of International Health, Maastricht University). “We need to recognise that today many functions of public health are part of primary care, and also have a role as a form of social compensation.”
Rector Smolle: conditions for enhanced role of general practitioners must be put in place
“GPs must play an important role in the implementation of the current healthcare reform,” said University Professor Dr Josef Smolle, Rector of the Medical University of Graz. “They have the decisive advantage of knowing and looking after their patients over a period of many years. So they can often solve health problems without any need for further treatment elsewhere. But if they are to perform this task optimally, notably when it comes to looking after and treating the growing number of chronically ill patients, two conditions must be met. Doctors need to be adequately paid for this. And we have to attach great importance, even more than at present, to good, thorough training of GPs.”
Significance of primary carers in implementing healthcare reforms
“In a great many OECD countries, not just in the EU's so-called crisis states, health spending as a proportion of GDP is falling,” said Dr Josep Figueras, Director of the European Observatory on Health Systems and Policy. “Given the ubiquitous cost containments, coupled with growing health requirements, we have no other option than to improve the performance of our health systems. Primary care providers have a central role to play in terms of implementing the kind of reforms being discussed in Europe, for instance greater cost-effectiveness in health care, cutting the amount of in-patient treatment, or more preventive medicine.”
International comparison: Austria not much focussed on primary care
“The challenges which face all health systems require innovation at many levels, such as enhanced focus on patients as a whole, not just on their illnesses, new approaches to education and training for health care providers, or a new distribution of tasks between the health professions,” said Dr Winke Boerma, Netherlands Institute of Health Services Research. “Primary carers, meaning as a rule GPs, have a lot more to offer in this area than merely being the first port of call and guides to through the health care system. Many health problems can be treated cost-effectively without the need for further action at higher levels of care.”
In health systems where GPs have a strong position they also play a “gate-keeper” role – meaning they decide whether patients can consult specialists or hospitals. Such systems, said Dr Boerma, citing current studies, were more effective in providing care, and could for instance prevent unnecessary hospital admissions. However, it had to be said that in countries whose health systems were based on this model there was less patient satisfaction, and the proportion of GDP spent on health in these systems was no lower than in countries which accorded primary care a less important role.
Austria, said the expert, had significantly more hospital beds than the European average, but at the same time far fewer GPs than countries with a below-average hospital density such as the Netherlands. There were a number of other peculiarities about Austria compared to countries with strong primary care, said Dr. Boerma, quoting a recent Europe-wide study (QUALICOPC Survey): 85 percent of Austrian GPs practised alone - in the Netherlands it was only 30 percent, with everyone else in group practices. Austrian GP offices were open for an average 7.5 hours per workday, in the Netherlands it is 10 hours. At the same time, Austrian GPs see about 50 patients on an average workday, in the Netherlands GPs deal with 30 patients per day. “Austria's current system is strongly focused on the secondary health care system,” said Dr Boerma, summing up the comparisons. “General practitioners are convinced that primary care is a struggle they have to take on alone; there is little in the way of coordinated, organised structures.”
Better health outcomes with well-organised primary care
“Expectations and responsibilities in primary care have changed – and expanded – dramatically,” said Prof Richard Saltmann, Rollins School of Public Health, Atlanta, Georgia (USA). “Primary care is increasingly centre-stage in public healthcare systems. Two trends for dealing with ever more complex demands can be observed. Either the role of general practitioners is expanded horizontally, making GPs essentially coordinators who guide their patients through all the other services offered by the health system. Or there is a vertical extension of their role, they become increasingly specialised in order to deal with major chronic illness without referring patients on to specialists.”
Where the role of primary carers has, in various ways, been specifically strengthened, in the UK or Denmark for instance, certain indicators have shown markedly better results, reported Prof Saltmann. This was the case in the UK, which saw a significant improvement in blood pressure or blood lipid levels among coronary heart disease patients following the introduction of the “Quality Outcomes Framework”; doctors working for the National Health Service were obliged to take part in this. “Healthcare policymakers have a complex task re-arranging and redefining the very diverse, often contradictory, role of general practitioners, and laying down appropriate conditions and regulatory measures as well as incentives,” said Prof Saltmann.
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