Developing effective primary care: A systems approach

1. Developing effective primary care:A systems approach Moscow, 8th December 2005 Josep Figueras European Observatory on Health Systems

2. Primary Care Reform Putting PC in the driving seat? • Giving more power and control to PC • Coordination and integration • Expanding range of interventions in PC

3. Primary Care Reform Putting PC in the driving seat? Stewardship (oversight) Responsiveness (to people’s non-medical expectations Primary Care Creating resources (investment and training) Delivering services (provision) Health Fair (financial) contribution Financing (collecting, pooling and purchasing WHO WHR 2000

4. Primary Care Reform Putting PC in the driving seat? • Beyond particular PC model of provision • Need for broad health system approach • Multilevel / simultaneous health system changes • Key to implementation success

5. Aligning financial incentives • Fragmented pools / multiple purchasers • Different sources (SHI, tax) / levels: local, regional,. • Diluted and sometimes contradictory incentives

6. Aligning financial incentives • Fragmented pools / multiple purchasers • Performance related payment systems? Finding the right mix: • Salary / Allowances • Capitation • Fee for service • Performance incentives

7. Aligning financial incentives • Fragmented pools / multiple purchasers • Performance related payment systems? “The only way to pay doctors is to change the system every three years, because by then they will have found ways to get round it to their own advantage” Bob Evans

8. Aligning financial incentives • Fragmented pools / multiple purchasers • Performance related payment systems? • Poor complementarity of design • E.g. capitation in PC & fee for service specialist care • Large share of out of pocket informal payments • Need to formalizing into cost sharing schemes

9. Croatia: wrong mix of incentives J Langenbrunner, 2005

10. Out Of Pocket PaymentsAs a % of Health Expenditures (2002) World Bank, 2005

11. Aligning financial incentives • Fragmented pools / no single payer • Performance related payment systems? • Poor complementarity of design • Large share of out of pocket informal payments • Lower income of GPs vis-à-vis specialists • Lower share of budget to primary care • In spite of increased emphasis/substitution policies • Less than 25% of overall budget in most countries • Only marginal increases in few countries

13. Aligning financial incentives • Fragmented pools / no single payer • Performance related payment systems? • Poor complementarity of design • Large share of out of pocket informal payments • Lower income of GPs vis-à-vis specialists • Lower share of budget to primary care • Giving primary care budgets / purchasing?

15. Accompanying human resources policy • Numbers alone mean little • PC reform constrained by professonal competence • Produce right number & mix of skills according to health needs, PC requirements & resources available • Coherent curricula development linked to PC model

16. Accompanying human resources policy • Strengthen professional recognition (nurses & GPs) • Specific field of knowledge is accepted • Academic body to develop it • Production of literature • External recognition by other specialties & society e • Strong professional organization • Self regulation • Representation • Quality standards

17. Adjusting to changing organizational structures • From command & control to steer & row • Decentralization to lower levels of government • Strategic purchasing / contracting • Privatisation of provision • Increased consumer choice • Self employed GPs under public contract

18. Strengthening regulation • Gatekeeping and referral systems • Setting expanded task profiles • Substitution between levels of care • Framework and rules for contracting • Open information, monitoring, evaluation • Licensing, certification and accreditation • Self regulation? • Information / communication systems

19. Issues • Gatekeeping vs consumer choice • Coordination/integration vs market competition • Substitution: not only transfer of patients…. but of skills, technology & financial resources

20. Provider competition Primary care Hospital Hospital Hospital Primary care Primary care M McKee

21. Integrated model Clinical networks Diagnostics Hospital Hospital Hospital Primary care Primary care Primary care M McKee

22. Shifting patients: substitution Skills? Technology? Resources?

23. Stepping up stewardship • Managerial difficulties: power, tools, technical skills • Institutional / organizational weaknesses • Overlap / fragmentation of responsibilities between institutions • Economic obstacles (substantial transaction costs) • Political obstacles • Distrust of the role of government per se • Weaknesses to enforce statutes and legislation • Cultural and organizational difficulties • Closed social networks between gov officials and providers • Change in the management culture of command and control

24. Primary Care Reform Putting PC in the driving seat? • Aligning financial incentives • Accompanying human resources strategies • Adjusting to changing organizational structures • Strengthening regulation • Stepping up stewardship

25. The European Observatory www.observatory.dk