Primary Health Care in the center - as part of integrated care

1. Primary Health Care in the center - as part of integrated care against the background of NCD burden and ageing population Workshop at the European Forum of Primary Care Biannual Conference The Future of Primary Health Care in Europe Tuesday 4 September 2012, Goteborg

2. Health 2020: Strengthen people-centred health systems and public health capacity Primary health care as a hub for people-centred health systems with ensured continuity Foster continuous quality improvement Improve access to affordable medicines Flexible, multi-skilled and team-oriented workforce Sustainable financing ensuring financial protection Governance arrangements promoting participation and transparency

3. World Health Day 2012EU Year of Active Ageing and Solidarity between Generations

4. WHO Strategy and action plan for healthy ageing in Europe, 2012-2020 Four strategic areas for action

5. 2011: The Year of Noncommunicabe Diseases

6. Discussion questions • State of the art of PHC in WHO European region • PHC – integrated care services • Best practices ? • Future directions

7. Challenges facingtheprimarycareprofessional in a changing Europe Anna Stavdal MD/GP Vice President WONCA Europe

8. Representing: • 22 membercountries, >80 000 members • GPs working in a diversityofhealthcare systems Main areas ofacivity: Research Education Quality and patientssafety www.woncaeurope.org

9. Somekeycharacteristicsofour time and place: • Migration, patients and doctors • Sosioecomic gaps arewidening, within and betweencountries • Great differenciesbetween European countries in developmentof PHC • New Public Management

10. Coremessages: • Values • Diseasemongering/overdiagnosing • Patients`rightsvsquality in healthcare

11. Values

12. Primary Care Oriented Countries Have: Better health outcomes Lower costs Greater equity in health • Fewer low birth weight infants • Lower infant mortality, especially postneonatal • Fewer years of life lost due to suicide • Fewer years of life lost due to “all except external” causes • Higher life expectancy at all ages except at age 80 Starfield 07/07 IC 3762 n Sources: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield & Shi, Health Policy 2002; 60:201-18.

13. «In hospitals diseasesstay and patientscome and go. In general practicepatientsstay and diseasescome and go» Iona Heath ‘The mystery of general practice’. London: Nuffield Provincial Hospitals Trust, 1995

14. Weneed GPs capableof: • takeonthe risk onbehalfoftheirpatientswhennecassary • willingtaketheresponsibilityofprioritizingthosewiththegreatestneedwithintheirpopulation • take pole position in theprimaryhealthcare team

15. Diseasemongering/ Overdiagnosing

16. Selfassessedhealth The healthyones HEALTH + Individuals at risk Doctor`sassessment ILL HEALTHY The sickones MUPS HEALTH -

17. «Anna`sdoctrine» Defendthebroad range ofnormalityof human biology and psyhology!!

18. patients`rights vs quality

19. New regulations for GPs in Norway: «80 % ofincomingphonecalls to be answeredwithin 2 minutes» «right to a consultationwithin 5 days, independentofcause» Real need or just consumers` demand?

20. The maintask for thePrimary Health Care professional is tobalancepoliticalambition, patientsrights and demands, and professionalquality in thedailywork

21. Thankyou for yourattention!

23. University of the West of Scotland • Scotland’s largest modern university with 20,000 students • Largest School of Health, Nursing and Midwifery in Scotland • Local university to 40% of Scotland’s population across four campuses • Representing EU funded, WHO supported Family Health Nursing project (FamNrsE)

24. Background • The World Health Organization (WHO) (2008) suggested that in the last three decades in general the population of the world is healthier and is living longer. • The global health challenges are significant. WHO (2009) outlined that the current leading global risks and causes of death around the world include; • High Blood Pressure: contributing to 13% of deaths (7.1 million people). • Tobacco use: contributing to 9% of deaths (4.9 million people). • High blood glucose contributing to 6% of deaths. The number of people • with diabetes is expected to double by 2030. • Physical inactivity contributing to 6% of deaths. • Overweight and obesity contributing to 5% of deaths. • Workforce challenges, demographics and the economy impact on the • workforce too.

25. What Should Concern Us: Common Ambition • Key overarching aim of HEALTH21: • “promoting and protecting people’s health throughout the course of their lives; and reducing the incidence of and suffering from the main diseases and injuries” (WHO, 1998, p. 8).

26. Developing a Road Map for Health Service Delivery (WHO Europe, Copenhagen, 2012) • Ageing population and workforce, with chronic diseases and multiple • morbidity, requires structural integration (based on defining needs of • population groups in integrated ways). • A bigger change in terms of increasing efficiency and re-shaping public • and provider expectations is needed, and case studies (e.g. chronic • condition management, emergency response etc) evaluating consistency • and efficiency of interventions should be used to develop recipes for • success (common denominator solutions). • The new approach to generalism appears to be the real challenge, and requires a transforming scenario leading to a new pattern of services • provided and accessed by educated patients, populations and providers.

27. Reinforced by EU FamNrsE Project There are both similarities and differences in the way health services are delivered within countries. This is due to a range of factors including population, organisational structure of health service and availability of resources and healthcare workforce. Each country has changing demographic profiles. Each country has similar public health issues including an ageing population and increasing long-term conditions such as Cardiovascular disease, Respiratory disease, Diabetes and Cancer.

28. Principles and Challenges • Progress cannot be made through professional or system isolation and • will involve collaboration with individuals, families, communities, • hospitals, Primary Health Care (PHC) teams, the public and private • sector. • PHC is part of the life-health journey – a continuum. • Future demands from compressed periods of complex co-morbidity. • Primary care is health and social care as a function but person centred • and team delivered. • “Specialist generalist” – needs recognised and rewarded. • Who is the gatekeeper – individual, clinical practitioner, health system?

29. Continuum of Care – a Model Promotion of Health and Wellbeing Promotion of Health and Wellbeing Martin and Duffy (2012) Do not quote without authors’ permission.

30. New Service Model

31. Proactive Tasks

32. Responsive Tasks

33. Core Observations We need to harness and share academic and professional experience across European countries. We need to strive for a consistency of approach with high quality standards, while recognising, encouraging and valuing local/national variation.

34. Governments Across Europe are encouraged to: • Put in place comprehensive public health policies responsive to the needs of the population at a community, regional, national and international level. • Make clear policy statements and resource commitments that • advance integrated approaches to the development and delivery • of accessible health systems. • Ensure that the health system is affordable to the local, regional • and national economy and at the point of access for the individual. • Promote  health and wellbeing with a focus on the prevention of • illness.

35. Governments across Europe are encouraged to: • Stimulate service models that are flexible, person centred and • designed to support people who present with complex co-morbidities. • Encourage community engagement and social enterprise • approaches to service development and delivery that foster • entrepreneurship and community sustainability. • Develop a health workforce based on the principles of team work and interdisciplinarity. • Recognise the core contribution of the “specialist generalist” role in the primary care setting.

36. Family Health Nursing in European Countries Berlin Conference 25th and 26th October 2012 http://www.uws.ac.uk/familyhealthnursing/ Thank you – Discussion

37. Hospitals and the challenges of Multi chronic conditions E de Roodenbeke, PhD Ceo of International Hospital Federation

38. INTERNATIONAL HOSPITAL FEDERATION The international organization is representing national hospital and health care organizations from all over the world • Sharing universal values for improved performance of health care services and better access to care for the population • World leader in facilitating the exchange of strategic knowledge and experience in the hospitals and health care delivering sector. • The voice of the hospitals and healthcare delivery industry and their decision makers in major international health organizations • Providing many opportunities for networking: Congress, Publications, Projects, Web, Training, …

39. Hospitals and Multi chronic conditions Hospitals: What are we talking about ? Challenges for hospitals to respond to chronic conditions and PHC approach Way forward to better face future 39

40. Hospitals: What are we talking about ? Are they similar? What is in common between a small rural hospital in a remote location and a large university hospital in a dense urban center? 40

41. Hospitals: What are we talking about ? Role and function vary between types of hospitals Role and functions vary within countries according to location (remote /urban) and ownership (public/private) Role and functions vary a lot between countries according to history, governance model, ownership  No international definition or classification of hospitals but a generic model can be elaborate: - recognize its nature as a production organization - interface it with policy options - identify its key inputs and outputs 41

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43. Role of Hospitals for Chronic Conditions Wellness Patient at Risk Critical episode Education & disease awareness Investigation & Monitoring Intervention & treatment plan H Recurrence ? Advanced disease Prevention & follow up Remote monitoring & care management Predictive care Mapping risks & advising 43 www.ihf-fih.org

44. Challenges for Hospitals with healthcare Continuity of care : make it happen!!

45. Challenges for Hospitals with healthcare Coordination : Who is in charge, how is it organized and financed? GP’s and

46. Challenges for Hospitals with healthcare From a specialty centered organization to a patient’s centered organization Education of doctors : hyper specialization Complexity and knowledge management : silo approach Quality of care & productivity : importance of volume Today’s hospitals are not well organized to deal with multi-chronic conditions : Transforming hospitals of all nature to better care and coordinate care Breaking down the large hospital model by an “industrial revolution” 46

47. Challenges for Hospitals with healthcare How to serve population in rural/remote places Care givers are reluctant to work alone Care givers are reluctant to leave in remote places  Initiatives to boost rural hospitals as hub for PHC  Promises from e-health in relation with health-hubs How to deal with inadequate utilization of hospitals: Emergency as an alternative to unavailable first line care Hospitals as a solution for social situations Important shortage of capacity in long term institutions  Invest in pre and post hospital alternatives to reduce pressure on hospitals 47

48. Challenges for Hospitals with healthcare Inadequate payment system in most countries : Activity based and only in relation to sole provider No recognition and payment of coordination  Full redesign of payment systems with multiple payments to better support different functions Payers and coverage do not favor innovation: Silo approach with competition between payers Coverage not supporting patient empowerment  Re-engineer the coverage mechanisms in relation with political decentralization

49. Way forward to better face future A need to bring clarity in the discussion on PHC Principles for health systems A package of low cost and high impact activities Organizations delivering health services to the population

50. Way forward to better face future PHC as a principle for health systems • Adoption by all stakeholders of the PHC principles with commitment to implement them in their activities : • Patient centered services • Patient empowerment • Quality and patient safety • Equity of access to health services • Accountability and transparency • Organizing continuity of care