Some recent changes and challenges in french primary care

1. Some recent changes and challenges in french primary care Isabelle Dupie, Hector Falcoff International Forum on Quality & Safety in Healthcare Paris, 8-11 1pril 2014

2. Conflicts of interest We have no conflict of interest related to this presentation.

3. A French paradox • The French health care system : • « a weak primary care system » (Macinko & Starfield, 2003) • « the best health care system in the world » (WHO, 2000) • Why ? Because we were rich ! • Universal health insurance • Primary care : unorganized but abundant • Big secondary and hospital care sector

4. Positive changes in the last 10 years • General practice becomes an academic discipline (2004) : titular professors, lecturers, PhD students… • Patient lists + gatekeeping role for GPs (2004). • Role of GPs defined by the law (2009). • A unique National College gathering the Unions, the academic and scientific societies, the CME/DP associations (2010). • Introduction (2011) of new types of payments : capitation, P4P (± 10% of the total earnings of the GPs). • Development of team work in PC : multi professional group practices called « Maisons de santé pluriprofessionnelles » ; 5-10% of GPs in 2014, 25% anticipated in 2020).

5. Two major challenges (Touraine, Lancet 2014) • How to keep our good health indicators and : • Contain health care cost (12 % GDP in 2013 !). • Reduce health inequalities which are « substantial » (European Commission, 2013).

6. Life expectancy at 35 years old in France Woman, executive Woman, manual worker Man, executive Man, manual worker

7. Equity • Définition : equal care for people with equal health needs. • Inverse care law : the availability of good medical care tends to vary inversely with the need for it in the population served (Hart 1971). • Can we change this ?

9. Why and how to register social information for an adult patient in general practice ?

10. Equity of primary care : next steps • Testing the feasability/acceptability of social data collection. • Dissemination of the guideline. • Implementation in medical records softwares • Development of equity indicators • Incentivisation • PDSA cycles… A LONG WAY TO GO !

11. Patient safety • National Plan for patient safety 2013-2017 • Most knowledge on patient safety come from hospitals : 4,5% hospitalizations due to serious adverse events occurred in the ambulatory sector Michel P et al.Enquête Nationale sur les évenements indésirables graves liés aux soins (ENEIS2) • Root Causes analysis Immediate failures were mainly: • therapeutic errors, • monitoring failures • And therapeutic delays. Most cases were adverse drug events, mainly related to anticoagulant drugs, neuroleptics and diuretics. Michel P et al. Les évenements indésirables graves liés aux soins extra hospitaliers:fréquence et analyse approfondie des causes,2009

12. What do we know? (1/2) ESPRIT 2013 : an innovative research program • A professional consensus on definition of Adverse Events (AEs) in Primary Care : "An adverse event is an event or circumstance associated to health care, that could cause or has caused harm to a patient and which, we hope not to happen again. » • The national incidence survey in Primary Care : 22 AEs /1000 contacts (visit - home visit - phone contact) • Quite frequent : 1 AE / 2days / GP • No harm for 3/4 AEs • 2% serious AEs

13. What do we know? (2/2) • Main types of risk situations identified by ESPRIT 2013 • Organization problems in medical practice • Prescription writing • Communication with patient • Lack of proper knowledge and skills mobilizing

14. What are we doing ? • Some local innovative experiences… • patient safety improvement activities • Mortality morbidity review • Adverse event analysis meeting • in multi professional staff or in peer groups or quality circles We need to organise data collection • Some ongoing studies - mainly on adverse drug events

15. A lot still to do… • Develop a safety culture among health care providers : • How to promote the definition of AE among professionals ? • How to detect Aes ? • Provide a reporting system • Why and How to report ? • Build a capacity to share and disseminate knowledge • How to learn from errors ? • Needs for research : better identify AEs’ contributing and recovering factors • How to reduce harm risk ?

16. Thank you for your attention !